Annals of emergency medicine
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Randomized Controlled Trial Comparative Study Clinical Trial
Vagal response varies with Valsalva maneuver technique: a repeated-measures clinical trial in healthy subjects.
Variable success rates of the Valsalva maneuver in treatment of paroxysmal supraventricular tachycardia may be due to variations in performance technique. This study aimed to compare the magnitude of the vagal reflexes initiated by 5 variations of the Valsalva maneuver technique (supine, supine with epigastric pressure, supine with leg raise, semirecumbent position, and sitting position). ⋯ For healthy subjects in sinus rhythm, the supine with epigastric pressure and supine techniques generated stronger vagal responses, as measured by R-R intervals and pulse rates, than the other techniques examined. However, the vagal responses of these 2 techniques were similar, and the addition of epigastric pressure may confer little advantage.
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Randomized Controlled Trial Multicenter Study Clinical Trial
A randomized, double-blinded, placebo-controlled trial of phenytoin for the prevention of early posttraumatic seizures in children with moderate to severe blunt head injury.
We determine the efficacy of prophylactic phenytoin in preventing early posttraumatic seizures in children with moderate to severe blunt head injury. ⋯ The rate of early posttraumatic seizures in children may be much lower than previously reported. Phenytoin did not substantially reduce that rate.
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Randomized Controlled Trial Multicenter Study Clinical Trial
Recalibration of the pediatric risk of admission score using a multi-institutional sample.
Case-mix adjustment is a critical component of quality assessment and benchmarking. The Pediatric Risk of Admission (PRISA) score is composed of descriptive, physiologic, and diagnostic variables that provide a probability of hospital admission as an index of severity. The score was developed and validated in a single tertiary pediatric hospital emergency department (ED) after exclusion of children with minor injuries and illnesses. We provide a multi-institutional recalibration and validation of the PRISA score and test its performance in 4 additional EDs, including patients with minor injuries and illnesses. ⋯ The PRISA score has been recalibrated and performs well in EDs of tertiary pediatric hospitals. Comparison with this benchmark may allow individual EDs to improve their performance and may provide insight into best practices.
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Review of emergency department pain management practices demonstrates pain treatment inconsistency and inadequacy that extends across all demographic groups. This inconsistency and inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include (1) a lack of educational emphasis on pain management practices in nursing and medical school curricula and postgraduate training programs; (2) inadequate or nonexistent clinical quality management programs that evaluate pain management; (3) a paucity of rigorous studies of populations with special needs that improve pain management in the emergency department, particularly in geriatric and pediatric patients; (4) clinicians' attitudes toward opioid analgesics that result in inappropriate diagnosis of drug-seeking behavior and inappropriate concern about addiction, even in patients who have obvious acutely painful conditions and request pain relief; (5) inappropriate concerns about the safety of opioids compared with nonsteroidal anti-inflammatory drugs that result in their underuse (opiophobia); (6) unappreciated cultural and sex differences in pain reporting by patients and interpretation of pain reporting by providers; and (7) bias and disbelief of pain reporting according to racial and ethnic stereotyping. This article reviews the literature that describes the prevalence and roots of oligoanalgesia in emergency medicine. It also discusses the regulatory efforts to address the problem and their effect on attitudes within the legal community.
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The purpose of this study is to determine what factors influence emergency physicians' decisions to prescribe an opioid analgesic for 3 common, painful conditions. ⋯ Even when faced with identical case scenarios, physicians' decisions to prescribe opioid analgesics are highly variable. Moreover, the same clinical information, such as a patient requesting a strong analgesic, changes the likelihood of prescribing opioids in opposite directions for different physicians.