Annals of emergency medicine
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Review Meta Analysis
The relative efficacy of meperidine for the treatment of acute migraine: a meta-analysis of randomized controlled trials.
Despite guidelines recommending against opioids as first-line treatment for acute migraine, meperidine is the agent used most commonly in North American emergency departments. Clinical trials performed to date have been small and have not arrived at consistent conclusions about the efficacy of meperidine. We performed a systematic review and meta-analysis to determine the relative efficacy and adverse effect profile of opioids compared with nonopioid active comparators for the treatment of acute migraine. ⋯ Clinicians should consider alternatives to meperidine when treating acute migraine with injectable agents.
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We identify geographic, system, and socioeconomic differences between injured children cared for within and outside of state-designated trauma centers. ⋯ We demonstrate considerable variation in the utilization pattern of trauma specialty care for children with moderate and severe injuries. Children with HMO and private insurance are cared for less often in trauma centers than those with public insurance, even after adjustment for other variables. Increased distance to a trauma center, as well as lack of trauma center within a county, also decreases trauma center utilization. These results suggest that assessing trauma center utilization patterns in total populations of children may identify opportunities for improved referral policies and practices as part of a larger effort to ensure high-quality trauma care for all children in need.
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Clinical Trial
Triage pain scores and the desire for and use of analgesics.
Inadequate analgesia (oligoanalgesia) is a common phenomenon. In an effort to improve pain recognition and management, pain scores are mandated by The Joint Commission. When patients with pain do not receive analgesics, treatment is considered deficient. However, the mere presence of pain does not imply that all patients desire analgesics. We determine how often patients in pain desire and receive analgesics in the emergency department (ED). We hypothesize that many ED patients in pain do not desire analgesics and that most who want them receive them. ⋯ Nearly half of all ED patients in pain do not desire analgesics and most who desire analgesics receive them. Although the average pain score for patients not wanting analgesics was lower, it was often in the moderate to severe range. Patients should be asked whether they have pain and whether they want analgesics regardless of their pain scores.
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Interest in regionalization of the care of acute ST-segment elevation myocardial infarction (STEMI) has gained momentum recently. Optimal treatment of STEMI involves balancing time to treatment and reperfusion options. Primary percutaneous coronary intervention, when performed in a timely fashion, has been shown to be more effective than fibrinolysis. ⋯ Therefore, we present various perspectives and issues that decisionmakers and system organizers must address properly before deciding whether to adopt this new model of care. Reorganizing STEMI care in a manner analogous to how trauma and stroke care are currently triaged and treated appeals intuitively; however, given the absence of evidence that STEMI regionalization actually improves patient outcomes and is cost-effective, more research is needed to determine whether STEMI regionalization is an efficient model for providing evidence-based care. The concept of STEMI regionalization represents an effort to inform policy according to evidence-based medicine, but real-world quality, geospatial, financial, cost, business, resource, and practice barriers present obstacles to implementing this concept efficiently and effectively.