Augmented ED

Augmented ED

The future of emergency medicine?

EPs in Rhode island overcome hurdles to trial Glass for telemedicine and consider other applications.

All About Metoclopramide (Reglan)

All About Metoclopramide (Reglan)

Know the risks

Reglan should be used with caution if patients have Parkinson’s disease or are on antipsychotics.

Physicians Won't Be Silenced

Physicians Won't Be Silenced

ACEP's Gag Order Rejected

EPM readers speak out against ACEP’s new ruling prohibiting incoming leaders from answering questions from non-ACEP publications.

Changemaker

Changemaker

How One EP Transformed Mental Health Admissions in Virginia

Debra Perina combined her experience as a coroner with her time leading an ED to challenge the establishment.

Get the Gear Off

Get the Gear Off

Removing the Helmet and Pads is Crucial to Treating Spinal Injuries from Football

Up to 25% of c-spine injuries from football collisions may be exacerbated by the poor removal of helmet and pads.

The War on Death

The War on Death

by Greg Henry, MD

The guns and butter debate is really over, I guess.

The Ebola Plan

The Ebola Plan

CDC Quarantine Map Shows that a U.S. Ebola Outbreak is Unlikely

Amid the worst outbreak of the Ebola virus in recorded history, there have been concerns that the disease could spread…

How Do I Know if I'm Being Paid Fairly?

How Do I Know if I'm Being Paid Fairly?

Trust is key

I get paid based on my productivity, but I don't trust that my company is paying me accurately.

The Stethoscope of the Future

The Stethoscope of the Future

Bedside Ultrasound

The applications of bedside ultrasound have gone well beyond scanning the gallbladder . . . to the lungs?

ICEM 2014

ICEM 2014

Tintinalli Headlines & Holliman Assumes Presidency

On June 11, EPM Editor-in- Chief and renowned educator Judith Tintinalli took to the stage in Hong Kong to address…

The Medical Malpractice Rundown: A State-by-State Report Card

The Medical Malpractice Rundown: A State-by-State Report Card

When it comes to medical liability laws and culture, where you live matters.

Find out how your state stacks up against the other 49.

CT – Lowering Cost and Radiation

CT – Lowering Cost and Radiation

Medicare pays only about 20% of typical charges and radiation can be reduced by 90%.

The cost of a CT is actually quite nominal – the charge, however, is an entirely different matter. 

 Aftermath: The Night Shift Season 1 Finale Review

Aftermath: The Night Shift Season 1 Finale Review

At Loose Ends

It’s strange calling this a season finale, because it’s only been an 8-episode summer run, and nearly every episode has…

Doximity’s Next Trick: Connectivity at the Point of Care

Doximity’s Next Trick: Connectivity at the Point of Care

You’ve raised $81 million in investments and your physician membership now exceeds that of the AMA. What’s next?

If you're Doximity, it's time to dream big. 

Subcutaneous Insulin in DKA: Safe — But Not Better

Subcutaneous Insulin in DKA: Safe — But Not Better

Newer Isn't Always Better

Studies show that the benefits of subcutaneous insulin over old fashioned IV insulin are marginal at best.

A Return to (Lousy) Form: Episode 7 of The Night Shift

A Return to (Lousy) Form: Episode 7 of The Night Shift

Forks! Strippers! Guns!

Once again, our characters are responding to the (frankly unbelievable) events unfolding around them, rather than driving the action.

Oxygen is a Drug— Act Accordingly

Oxygen is a Drug— Act Accordingly

Understanding the dangers of indiscriminate oxygenation in the ED setting

As with many things in medicine, dogma seems to overpower the evidence in this arena. 

Oh Henry: A Sucker is Born Every Minute

Oh Henry: A Sucker is Born Every Minute

Pharmaceutical Ads, Government, and the Physician-Patient Relationship

Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


Gag Order

Gag Order

New ruling prohibits would-be ACEP leaders from answering questions from non-ACEP publications.

Greg Henry seldom fails to deliver on a promise. But this time, it looks like it’s out of his control.

The Downside of the Upswing

The Downside of the Upswing

You should have cashed in big-time. 
But did you?

The last several years of returns have been among the best ever.

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    Earlier in the night, you saw a 41 year old with fever, headache, and neck pain.  The labs are back and it does not appear that he has meningitis.  You have just explained this to him, and are walking out of the room, when he complains to you that the LP hurt more than he had expected.  Last year he had an LP for the worst headache of his life and he barely felt a thing.  While initially shocked since you consider yourself one of the “nicer” docs in your group as you use eutectic mixture of local anesthetics (EMLA) prior to performing an LP, you begin to wonder if there is a superior product on the market.

    This meta-analysis included 25 randomized control trials.  The trials compared the efficacy of topical anesthetics to dermal infiltration with local anesthetics and also compared those topical anesthetics to EMLA.  The trials included both men and women who were 3 years old and above.  The authors felt 3 years was the lowest age that children could credibly quantify pain.  All trials had to use some validated pain score such as the visual analogue scale (VAS).  In order to minimize the variability in the meta-analysis, the trials could only involve certain superficial procedures (intravenous cannulation, venipuncture) or deeper instrumentation (arterial cannulation, lumbar puncture).  Studies involving non-intact skin (laceration repair) were not included.  Also all studies involving EMLA had to apply it for at least 45 minutes before the procedure.  The manufacturer suggests one hour, but per the authors, EMLA has been found to work after 45 minutes of application.
   
Ten trials compared EMLA to infiltration with local anesthetic with mixed results.  Five studies involved superficial procedures and five involved deep procedures.  In both subgroups the results were mixed with some trials showing a greater efficacy in EMLA and some showing dermal infiltration to be superior.  Because of significant heterogeneity, the studies involving deep infiltration were not statistically combined.  No study compared EMLA plus local infiltration to either one alone.  The EMLA patch was also compared to EMLA cream in 4 trials.  The analgesic efficacy of each product was found to be the same.  Two of these studies had their results statistically combined but still did not find a statistical difference on the visual analogue pain scale.
   
One study compared lidocaine ointment (xylocaine) to EMLA when used for analgesia in intravenous cannulation.  EMLA was found to be superior; however, it only included 7 patients.  Liposomal lidocaine cream (LMX) was also compared to EMLA in 2 studies.  Both studies found them to have an equivalent amount of analgesia.  In both studies EMLA was applied 60 minutes before the procedure and LMX was applied 30 minutes before the procedure.  Since LMX only had to be applied half as long to work just as well as EMLA, it was concluded to be preferable to EMLA.  When LMX was applied for 60 minutes, the patient did not receive a greater amount of analgesia compared to when it was applied for 30 minutes.  The studies used different pain scales so their results could not be combined.
   
One study compared tetracaine gel to local infiltration in arterial puncture and found comparable efficacy.  Four trials compared tetracaine gel versus EMLA.  In all 4 trials, topical tetracaine was found to provide greater analgesia than EMLA.  However in one of the trials, the difference was not statistically significant. Three trials used the VAS and had their results combined.  Once again a difference favoring tetracaine gel was found to be statistically significant.  However the weighted mean difference of 8.1 mm on the pain scale is less than the 13 mm other studies have found as the minimum decrease in pain that is clinically significant.
   
The last 2 studies compared liposomal encapsulated tetracaine (LET) to EMLA in superficial instrumentation.  Both trials concluded that LET had a greater efficacy even though one trial did not show a statistically significant difference.  When the results of the trials were combined, LET was concluded to be more efficacious.  While the results were statistically significant the difference was still less than the 13 mm found to be clinically significant.
   
While most results were mixed, the authors were able to draw some conclusions.  When EMLA was compared to local infiltration, there was no difference in analgesia.  However since the application of EMLA is painless, whereas local infiltration is painful, EMLA is preferable to local infiltration.  While LMX was not found to have an increase in analgesia compared to EMLA, it did offer two benefits.  First it only had to be applied half as long to work just as well.  Second LMX ($42 for 30 gram tube) is cheaper than EMLA cream ($51 for 30 gram tube). 
 
 

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