Due to the healthcare burden associated with migraines, prompt and effective treatment is vital to improve patient outcomes and ED workflow. This was a prospective, randomized, double-blind trial. Adults who presented to the ED with a diagnosis of migraine from August of 2019 to March of 2020 were included. Pregnant patients, or with renal impairment were excluded. Patients were randomized to receive intravenous magnesium, prochlorperazine, or metoclopramide. The primary outcome was change in pain from baseline on a numeric rating scale (NRS) evaluated at 30 min after initiation of infusion of study drug. Secondary outcomes included NRS at 60 and 120 min, ED length of stay, necessity for rescue analgesia, and adverse effects. A total of 157 patients were analyzed in this study. Sixty-one patients received magnesium, 52 received prochlorperazine, and 44 received metoclopramide. Most patients were white females, and the median age was 36 years. Hypertension and migraines were the most common comorbidities, with a third of the patients reporting an aura. There was a median decrease in NRS at 30 min of three points across all three treatment arms. The median decrease in NRS (IQR) at 60 min was −4 (2–6) in the magnesium group, −3 (2–5) in the metoclopramide group, and − 4.5 (2–7) in the prochlorperazine group ( p = 0.27). There were no statistically significant differences in ED length of stay, rescue analgesia, or adverse effects. Reported adverse effects were dizziness, anxiety, and akathisia. No significant difference was observed in NRS at 30 min between magnesium, metoclopramide and prochlorperazine.

ObjectivesOur objective was to compare outcomes of discharge disposition, need for additional medications, and restraint use for patients who received inhaled loxapine compared with patients receiving traditional antipsychotic drugs in the emergency department (ED).MethodsA retrospective chart review was conducted on all patients who presented to the ED with agitation and received antipsychotic therapy, including loxapine, ziprasidone, or haloperidol from December 1, 2014, through October 31, 2016.ResultsThe mean time from physician assignment to medical clearance was 7.9 hours for patients treated with inhaled loxapine versus 10.3 hours for controls (P < 0.01). Those who received inhaled loxapine were given significantly less benzodiazepines as additional rescue medications as compared with other antipsychotic medications (P < 0.01, 35.2% vs 65.1%). Additionally, restraints were utilized less frequently in the loxapine group (P < 0.01, 1.8% vs 19.8%).ConclusionsTreating patients with agitation due to psychotic episodes in an ED setting with inhaled loxapine versus haloperidol or ziprasidone was associated with significantly improved treatment outcomes, suggesting that inhaled loxapine may be a more effective and rapid treatment option.

Background: Acute stress impairs physician decision-making and clinical performance in resuscitations. Mental skills training, a component of the multistep, cognitive-behavioral technique of stress inoculation, modulates stress response in high-performance fields. Objective: We assessed the effects of mental skills training on emergency medicine (EM) residents’ stress response in simulated resuscitations as well as residents’ perceptions of this intervention. Methods: In this prospective, educational intervention trial, postgraduate year-2 EM residents in seven Chicago-area programs were randomly assigned to receive either stress inoculation training or not. One month prior to assessment, the intervention group received didactic training on the “Breathe, Talk, See, Focus” mental performance tool. A standardized, case-based simulation was used for assessment. We measured subjective stress response using the six-item short form of the Spielberger State-Trait Anxiety Inventory (STAI-6). Objective stress response was measured through heart rate (HR) and heart rate variability (HRV) monitoring. We measured subjects’ perceptions of the training via survey. Results: Of 92 eligible residents, 61 participated (25 intervention; 36 control). There were no significant differences in mean pre-/post-case STAI-6 scores (-1.7 intervention, 0.4 control; p = 0.38) or mean HRV (-3.8 milliseconds [ms] intervention, -3.8 ms control; p = 0.58). Post-assessment surveys indicated that residents found this training relevant and important. Conclusion: There was no difference in subjective or objective stress measures of EM resident stress response after a didactic, mental performance training session, although residents did value the training. More extensive or longitudinal stress inoculation curricula may provide benefit.

Study Objectives: The 2010 Centers for Disease Control guidelines recommend presumptive treatment of Neisseria gonorrhea and Chlamydia trachomatis for men with urethritis and women with cervicitis who are at increased risk for sexually transmitted infection (STI) and in whom reliable follow-up cannot be ensured. We sought to compare the proportion of men and women tested for STI that accurately received presumptive antimicrobial treatment.Methods: A retrospective chart review was performed on 639 patient encounters that underwent both gonorrhea and chlamydia nucleic acid amplification testing (NAAT) during a single month in July of 2012 at an urban Level 1 trauma center emergency department. Each encounter was reviewed for NAAT result, if presumptive treatment was rendered and the accuracy of treatment. Presumptive antimicrobial treatment was considered accurate if a NAAT result was positive and appropriate antimicrobial treatment was rendered. Wilcoxon signed-rank test was used to compare average age of men and women tested. Chi-square and Fisher's exact tests were used to compare the proportion of men and women with positive NAAT result, those provided presumptive treatment, and the accuracy of those treated.Results: There were 639 patient encounters reviewed. There were 82 (12.8%) men and 557 (88.9%) women. The average age of men was significantly older than women, 29.5 versus 26.3 years (P<.031). Gonorrhea was more prevalent among men, 17.1% (N¼14) versus 3.2% (N¼18) (P<.001). Chlamydia prevalence was not statistically different between men and women, 14.6% (N¼12) versus 10.6% (N¼59) (P¼.277). Men received presumptive treatment more frequently, 82.9% (N¼68) versus 37.7% (N¼210) (P<.001). Men were more frequently provided accurate presumptive treatment, 24.4% (N¼20) versus 7.7% (N¼43) (P<.001).Conclusion: Presumptive treatment for gonorrhea and chlamydia was more frequent and more accurate in men tested for STI when compared to women. Presumptive treatment may be more appropriate in men than in women. However, the significant morbidity associated with these diseases makes undertreatment concerning in women. Future studies should evaluate use of an accurate rapid assay or reliable follow-up system, which may allow for more accurate treatment in women.

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