Mass-Gathering Medicine studies have identified variables that predict greater patient presentation rates (PPRs) and transport to hospital rates (TTHRs). This is a descriptive report of patients who presented for medical attention at an annual electronic dance music festival (EDMF). At this large, single EDMF in New York City (NYC; New York, USA), the frequency of patient presentation, the range of presentations, and interventions performed were identified. This descriptive report examined consecutive patients who presented to the medical tent of a summertime EDMF held at an outdoor venue with an active, mobile, bounded crowd. Alcohol was available for sale. Entry was restricted to persons 18 years and older. The festival occurred on three consecutive days with a total cumulative attendance of 58,000. Medical staffing included two Emergency Medicine physicians, four registered nurses, and 86 Emergency Medical Services (EMS) providers. Data collected included demographics, past medical history, vital signs, physical exam, drug and alcohol use, interventions performed, and transport decisions. Eighty-four patients were enrolled over 2.5 days. Six were transported and zero died. The ages of the subjects ranged from 17 to 61 years. Forty-three (51%) were male. Thirty-eight (45%) initially presented with abnormal vital signs; four (5%) were hyperthermic. Of these latter patients, 34 (90%) reported ingestions with 3,4-methylenedioxymethamphetamine (MDMA) or other drugs. Eleven (65%) patients were diaphoretic or mydriatic. The most common prehospital interventions were intravenous normal saline (8/84; 10%), ondansetron (6/84; 7%), and midazolam (3/84; 4%). Electronic dance music festivals are a growing trend and a new challenge for Mass-Gathering Medicine as new strategies must be employed to decrease TTHR and mortality. Addressing common and expected medical emergencies at mass-gathering events through awareness, preparation, and early, focused medical interventions may decrease PPR, TTHR, and overall mortality. Friedman MS , Plocki A , Likourezos A , Pushkar I , Bazos AN , Fromm C , Friedman BW . A prospective analysis of patients presenting for medical attention at a large electronic dance music festival. Prehosp Disaster Med. 2017; 32(1):78-82.

Background Despite guidelines recommending against opioids as first line treatment for acute migraine, meperidine is the agent used most commonly in North American emergency departments (ED). 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 side effect profile of opioids compared to non-opioid active comparators for the treatment of acute migraine. Methods We searched multiple sources (Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and LILACS, emergency and headache medicine conference proceedings) for randomized controlled trials comparing parenteral opioid and non-opioid active comparators for the treatment of acute migraine headache. Our primary outcome was relief of headache. If this was unavailable, we accepted rescue medication use or we transformed Visual Analog Scale (VAS) change scores using an established procedure. We grouped studies by comparator: a regimen containing dihydroergotamine (DHE), anti-emetic alone, or ketorolac. For each study, we calculated an odds ratio (OR) of headache relief and then assessed clinical and statistical heterogeneity for the group of studies. We then pooled the ORs of headache relief using a random effects model. Results From 899 citations, 19 clinical trials were identified, of which 11 were appropriate and had available data. Four trials compared meperidine to DHE, four compared meperidine to an anti-emetic, and three compared meperidine to ketorolac. Meperidine was less effective than DHE at providing headache relief (OR = 0.30; 95% CI: 0.09, 0.97) and trended towards less efficacy than the antiemetics (OR = 0.46; 95% CI: 0.19, 1.11); however, the efficacy of meperidine was similar to ketorolac (OR = 1.75; 95% CI: 0.84, 3.61). Compared to DHE, meperidine caused more sedation (OR = 3.52; 95% CI: 0.87, 14.19) and dizziness (OR = 8.67; 95% CI: 2.66, 28.23). Compared to the anti-emetics, meperidine caused less akathisia (OR = 0.10; 95% CI: 0.02, 0.57). Meperidine and ketorolac use resulted in similar rates of gastro-intestinal side effects (OR = 1.27; 95% CI: 0.31, 5.15) and sedation (OR = 1.70; 95% CI: 0.23, 12.72). Conclusion Meperidine is less efficacious and associated with more side effects than DHE regimens in acute migraine headache. There was also a trend towards decreased efficacy of meperidine compared to anti-emetics. There were no statistically significant differences in efficacy between meperidine and ketorolac. Clinicians should consider alternatives to meperidine when treating acute migraine with injectable agents.

Introduction We aimed to validate previously derived clinical criteria to predict successful prehospital response to naloxone in patients with altered mental status treated by EMS. We hypothesized that prehospital naloxone criteria would have high sensitivity for effective antidote response, but would be underutilized, in patients with drug-related altered mental status (DRAMS). Methods This study was a secondary data analysis of a prospective cohort of acute DRAMS at an urban ED. Naloxone criteria (respiratory rate (RR) <12, miotic pupils, or drug paraphernalia) and mental status, graded by either AVPU (Alert, Verbal, Painful, Unresponsive) or Glasgow Coma Scales, were abstracted from prehospital care reports. Interventions were compared for effective antidote response (EAR), defined as immediate improvement in RR, AVPU, or GCS. Results EMS transported 249 DRAMS over 17 months (48 % males, mean age 41.5, ALS 33.7 %). Forty-three (17 %) patients met naloxone criteria, of whom 44.2 % received the antidote. Naloxone criteria significantly predicted EAR (OR 7.0, p < 0.05) with 83 % sensitivity (95 % CI, 55-95 %). Miotic pupils (OR 20.0, p < 0.01) outperformed RR (OR 2.3, p = NS) as the best single criterion with 91 % sensitivity (95 % CI, 62-98 %). Conclusions This study validates prehospital criteria to guide naloxone administration. In addition, prehospital naloxone was underutilized for DRAMS. Further studies should address potential barriers to prehospital naloxone administration.

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The National Association of Emergency Medicine Services (EMS) Physicians (NAEMSP) recognizes the continued growth and complexity of mass gathering events and the integral role of the medical director in their planning and management. There is a growing body of literature that provides additional insight into patient presentations as well as preparation, staffing, and planning for these events. The clinical practice of EMS medicine encompasses the provision of care in a variety of out-of-hospital environments, including those defined as mass gathering events. This updated guidance is intended for use by EMS personnel, EMS medical directors, emergency physicians, and other members of the multidisciplinary care team as they strive to provide the best care for patients in a variety of out-of-hospital environments. This document is not meant to be a complete review of all the issues on this topic, but rather a consensus statement based on the combination of available peer-reviewed, published evidence and expert opinion.