1
|
Jain A, Pandey S, Sonakar S, Gupta P, Chaurasia R, Banoria N. On-Arrival Lumbar Epidural Analgesia for Lower Limb Trauma Pain in Emergency Care: A Superiority Randomized Controlled Trial. Cureus 2024; 16:e54622. [PMID: 38384869 PMCID: PMC10880870 DOI: 10.7759/cureus.54622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Lower limb trauma in emergency settings often leads to pain management challenges. Traditional methods, primarily non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, have limitations. This study explores the efficacy of epidural analgesia in emergency for lower limb trauma patients (ELETRA) as an alternative for managing pain in lower limb trauma patients upon arrival in emergency care. OBJECTIVES This study primarily focuses on determining ELETRA's effectiveness in reducing pain for patients with lower limb trauma upon arrival. It also aims to evaluate ELETRA's influence on decreasing stress and shortening hospital stays compared to traditional pain management approaches. METHODS This study was executed as a prospective, parallel-design, randomized controlled trial in the emergency department of a tertiary care teaching hospital. The interventions were performed in a dedicated induction room adjacent to the emergency operating theater. The trial was registered in the Clinical Trial Registry of India with registration number CTRI/2022/08/044699 dated 16/08/2022. Participants were 18- to 50-year-old patients with lower limb injuries, classified under American Society of Anesthesiologists (ASA) class 1 or 2. Participants were randomized into two groups: one receiving ELETRA and the other standard pain control treatment. The effectiveness of pain relief was measured through a visual analog scale (VAS), and hemodynamic parameters, adverse effects, levels of acute phase reactants, and stress hormones were also measured along with patient satisfaction. RESULTS The study enrolled 356 participants with lower limb injuries. After excluding participants lost following the intervention, data from 157 individuals in Group A and 160 in Group B were analyzed. Group A's success rate for analgesia (VAS < 2) was 92.35% (n = 145), significantly higher than Group B's 75.62% (n = 121) (p < 0.001). The commonest side effect was hypotension (5.73%) in Group A and nausea in Group B (7.5%). C-reactive protein (CRP) levels rose to 104.71 ± 8.99 mg/dL in Group A and 192.58 ± 9.23 mg/dL in Group B; the difference was statistically significant. Serum cortisol levels were also higher in Group B (67.18 ± 9.21) compared to Group A (44.72 ± 6.14) at one week. Group B had a longer hospital stay, averaging 12.24 ± 4.81 days, against Group A's 10.19 ± 4.91 days. CONCLUSION ELETRA is a safe and effective alternative for pain management in lower limb trauma patients in emergency settings. It reduces pain, improves patient satisfaction, and has a favorable impact on stress responses.
Collapse
Affiliation(s)
- Anshul Jain
- Department of Anesthesiology, Maharani Laxmi Bai Medical College, Jhansi, IND
| | - Shivali Pandey
- Department of Anesthesiology, Maharani Laxmi Bai Medical College, Jhansi, IND
| | - Shivanand Sonakar
- Department of Anesthesiology, Maharani Laxmi Bai Medical College, Jhansi, IND
| | - Paras Gupta
- Department of Orthopedics, Maharani Laxmi Bai Medical College, Jhansi, IND
| | - Rachna Chaurasia
- Department of Radiodiagnosis, Maharani Laxmi Bai Medical College, Jhansi, IND
| | - Neeraj Banoria
- Department of Surgery, Maharani Laxmi Bai Medical College, Jhansi, IND
| |
Collapse
|
2
|
Zanza C, Saglietti F, Tesauro M, Longhitano Y, Savioli G, Balzanelli MG, Romenskaya T, Cofone L, Pindinello I, Racca G, Racca F. Cardiogenic Pulmonary Edema in Emergency Medicine. Adv Respir Med 2023; 91:445-463. [PMID: 37887077 PMCID: PMC10604083 DOI: 10.3390/arm91050034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/28/2023]
Abstract
Cardiogenic pulmonary edema (CPE) is characterized by the development of acute respiratory failure associated with the accumulation of fluid in the lung's alveolar spaces due to an elevated cardiac filling pressure. All cardiac diseases, characterized by an increasing pressure in the left side of the heart, can cause CPE. High capillary pressure for an extended period can also cause barrier disruption, which implies increased permeability and fluid transfer into the alveoli, leading to edema and atelectasis. The breakdown of the alveolar-epithelial barrier is a consequence of multiple factors that include dysregulated inflammation, intense leukocyte infiltration, activation of procoagulant processes, cell death, and mechanical stretch. Reactive oxygen and nitrogen species (RONS) can modify or damage ion channels, such as epithelial sodium channels, which alters fluid balance. Some studies claim that these patients may have higher levels of surfactant protein B in the bloodstream. The correct approach to patients with CPE should include a detailed medical history and a physical examination to evaluate signs and symptoms of CPE as well as potential causes. Second-level diagnostic tests, such as pulmonary ultrasound, natriuretic peptide level, chest radiograph, and echocardiogram, should occur in the meantime. The identification of the specific CPE phenotype is essential to set the most appropriate therapy for these patients. Non-invasive ventilation (NIV) should be considered early in the treatment of this disease. Diuretics and vasodilators are used for pulmonary congestion. Hypoperfusion requires treatment with inotropes and occasionally vasopressors. Patients with persistent symptoms and diuretic resistance might benefit from additional approaches (i.e., beta-agonists and pentoxifylline). This paper reviews the pathophysiology, clinical presentation, and management of CPE.
Collapse
Affiliation(s)
- Christian Zanza
- Post Graduate School of Geriatric Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
| | - Francesco Saglietti
- Department of Emergency and Critical Care, Santa Croce and Carle Hospital, 12100 Cuneo, Italy
| | - Manfredi Tesauro
- Post Graduate School of Geriatric Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Emergency Medicine, Humanitas University Hospital, 20089 Rozzano, Italy
| | - Gabriele Savioli
- Emergency Department, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | | | - Tatsiana Romenskaya
- Department of Physiology and Pharmacology, Sapienza University of Rome, 00185 Rome, Italy
| | - Luigi Cofone
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (L.C.); (I.P.)
| | - Ivano Pindinello
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, 00185 Rome, Italy; (L.C.); (I.P.)
| | - Giulia Racca
- Division of Anesthesia and Critical Care Medicine, AO Ordine Mauriziano, 10128 Turin, Italy; (G.R.)
| | - Fabrizio Racca
- Division of Anesthesia and Critical Care Medicine, AO Ordine Mauriziano, 10128 Turin, Italy; (G.R.)
| |
Collapse
|
3
|
Zanza C, Saglietti F, Giamello JD, Savioli G, Biancone DM, Balzanelli MG, Giordano B, Trompeo AC, Longhitano Y. Effectiveness of Intranasal Analgesia in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1746. [PMID: 37893464 PMCID: PMC10608673 DOI: 10.3390/medicina59101746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023]
Abstract
In the Emergency Department (ED), pain is one of the symptoms that are most frequently reported, making it one of the most significant issues for the emergency physician, but it is frequently under-treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondly, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a narrative review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library, and Controlled Trials Register, finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia, showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. Intravenous is simple to administer, non-invasive, rapid onset, and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management.
Collapse
Affiliation(s)
- Christian Zanza
- Italian Society of Prehospital Emergency Medicine-SIS 118-Taranto, 74121 Taranto, Italy
- Post Graduate School of Geriatric Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Francesco Saglietti
- Department of Anesthesia and Critical Care, Santa Croce and Carle Hospital, 12100 Cuneo, Italy
| | | | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | | | | | - Benedetta Giordano
- Department of Human Neuroscience, Sapienza University of Rome, 00185 Roma, Italy
| | - Anna Chiara Trompeo
- Department of Anesthesia and Critical Care, AOU Città della Scienza e della Salute, 10126 Torino, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
- Department of Emergency Medicine, Humanitas University, 20089 Milan, Italy
| |
Collapse
|
4
|
Darnall BD, Edwards KA, Courtney RE, Ziadni MS, Simons LE, Harrison LE. Innovative treatment formats, technologies, and clinician trainings that improve access to behavioral pain treatment for youth and adults. FRONTIERS IN PAIN RESEARCH 2023; 4:1223172. [PMID: 37547824 PMCID: PMC10397413 DOI: 10.3389/fpain.2023.1223172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Chronic pain is prevalent across the life span and associated with significant individual and societal costs. Behavioral interventions are recommended as the gold-standard, evidence-based interventions for chronic pain, but barriers, such as lack of pain-trained clinicians, poor insurance coverage, and high treatment burden, limit patients' ability to access evidenced-based pain education and treatment resources. Recent advances in technology offer new opportunities to leverage innovative digital formats to overcome these barriers and dramatically increase access to high-quality, evidenced-based pain treatments for youth and adults. This scoping review highlights new advances. First, we describe system-level barriers to the broad dissemination of behavioral pain treatment. Next, we review several promising new pediatric and adult pain education and treatment technology innovations to improve access and scalability of evidence-based behavioral pain treatments. Current challenges and future research and clinical recommendations are offered.
Collapse
Affiliation(s)
- Beth D. Darnall
- Stanford Pain Relief Innovations Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Karlyn A. Edwards
- Stanford Pain Relief Innovations Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Rena E. Courtney
- Salem VA Health Care System, PREVAIL Center for Chronic Pain, Salem, VA, United States
- Virginia Tech Carilion School of Medicine, Department of Psychiatry and Behavioral Medicine, Roanoke, VA, United States
| | - Maisa S. Ziadni
- Systems Neuroscience and Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Laura E. Simons
- Biobehavioral Pediatric Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Lauren E. Harrison
- Biobehavioral Pediatric Pain Lab, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States
| |
Collapse
|
5
|
Savioli G, Ceresa IF, Bressan MA, Piccini GB, Varesi A, Novelli V, Muzzi A, Cutti S, Ricevuti G, Esposito C, Voza A, Desai A, Longhitano Y, Saviano A, Piccioni A, Piccolella F, Bellou A, Zanza C, Oddone E. Five Level Triage vs. Four Level Triage in a Quaternary Emergency Department: National Analysis on Waiting Time, Validity, and Crowding-The CREONTE (Crowding and RE-Organization National TriagE) Study Group. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040781. [PMID: 37109739 PMCID: PMC10143416 DOI: 10.3390/medicina59040781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.
Collapse
Affiliation(s)
- Gabriele Savioli
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Maria Antonietta Bressan
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Angelica Varesi
- Faculty of Medicine, University of Pavia, 27100 Pavia, Italy
| | - Viola Novelli
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Alba Muzzi
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Sara Cutti
- Health Department, University of Pavia, 27100 Pavia, Italy
| | | | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy
| | - Antonio Voza
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Desai
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Angela Saviano
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Fabio Piccolella
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Abdel Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Christian Zanza
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| |
Collapse
|