Objectives: Patients report pain and discomfort with nasogastric tube (NGT) intubation. We tested the hypothesis that premedication with midazolam alleviates pain during NGT placement in the emergency department (ED) by > 13 on a 100-mm visual analog scale (VAS). Methods:We performed a double-blind randomized controlled pilot study, assigning ED patients requiring NGT placement to midazolam or placebo. All patients received intranasal cophenylcaine; additionally, they received an intravenous (IV) dose of the study drug, either 2 mg of IV midazolam or saline control. Nurses placed NGTs while observed by research staff, who then interviewed subjects to determine the primary outcome of pain using a VAS. Additional data collected from patients and their nurses included discomfort during the procedure, difficulty of tube insertion, and complications.Results: We enrolled 23 eligible patients and obtained complete data in all: 10 midazolam and 13 controls. We found a significant reduction in mean pain VAS score of À31 (95% confidence interval = À53 to À9 mm) with 2 mg of midazolam (mean AE SD = 52 AE 30 mm), compared to placebo (mean AE SD = 21 AE 18 mm), more than double the effect size considered clinically relevant. Treatment did not impact ease of placement and there were no serious adverse effects. Conclusions:Premedication with 2 mg of IV midazolam reduces pain of NGT insertion in ED patients without the need for full procedural sedation.ACADEMIC EMERGENCY MEDICINE 2016;23:766-771

BACKGROUND: Carbon monoxide (CO) exposure causes roughly 40,000 emergency department (ED) visits annually and is commonly misdiagnosed. Whereas the standard method of carboxyhemoglobin (HbCO) measurement utilizes blood gas analysis, a noninvasive, FDA-cleared alternative exists. We evaluated the performance of pulse oximetry (S pCO ) for identification of CO exposure in ED patients. METHODS: We compared pulse oximetry to blood HbCO levels in a prospective observational study of adult and pediatric subjects recruited from the ED. Nurses screened a convenience sample of patients and referred those with S pCO > 10% to research staff. Researchers also approached individuals who presented with signs and symptoms of CO toxicity. We determined diagnostic performance with a Bland-Altman analysis and calculated sensitivity and specificity for detection of elevated HbCO at thresholds of > 10% and > 15%. To optimize the potential sensitivity of S pCO for detection of CO toxicity, research technicians performed 3 S pCO readings within 5 min of the blood draw for laboratory measurement. A positive S pCO test was defined as any S pCO > 10%. RESULTS: 42,000 patients were screened, 212 were evaluated, and 126 subjects were enrolled. Median HbCO level was 6% (range 1.6 -21.9%). Limits of agreement were ؊10.3% and 8.1%. Of 23 individuals with elevated HbCO > 10%, 13 were not suspected based on clinical assessment. Critically elevated HbCO was present in 6 individuals. Based on our a priori threshold of 10% for a positive test, pulse oximetry identified 14 of 23 subjects with HbCO > 10%, with a sensitivity of 61% (95% CI 39-80%) and a specificity of 86% (95% CI 78-92%), and 5 of 6 subjects with HbCO > 15%, with a sensitivity of 83% (95% CI 36-100%) and a specificity of 81% (95% CI 73-87%). CONCLUSIONS: Pulse oximetry underestimated HbCO and produced false negative results (ie, S pCO < 10% for all three measurements) in 17% of ED subjects with elevated HbCO > 15%. Triage screening with pulse oximetry detected cases of elevated HbCO that were not suspected by the clinical provider.