Background Acute pain is a common reason for emergency department (ED) attendance. Royal College of Emergency Medicine (RCEM) pain management audits have shown national variation and room for improvement. Previous evidence suggests that children receive less satisfactory pain management than adults. Methods Prescription of analgesia in emergency medicine is a cross-sectional observational study of consecutive patients presenting to 12 National Health Service EDs with an isolated long bone fracture and/or dislocation, and was carried out between 2015 and 2017. Using the recommendations in the RCEM Best Practice Guidelines, pain management in ED was assessed for differences of age (adults vs children) and hospital type (children’s vs all patients). Results From the total 8346 patients, 38% were children (median age 8 years). There was better adherence to the RCEM guidance for children than adults (24% (766/3196) vs 11% (579/5123)) for the combined outcome of timely assessment, pain score and appropriate analgesia. In addition, children were significantly more likely than adults to receive analgesia appropriate to the pain score (of those with a recorded pain score 67% (1168/1744) vs 52% (1238/2361)). Children’s hospitals performed much better across all reported outcomes compared with general hospitals. Conclusions In contrast to previous studies, children with a limb fracture/dislocation are more likely than adults to have a pain score documented and to receive appropriate analgesia. Unexpectedly, children’s EDs performed better than general EDs in relation to timely and appropriate analgesia but the reasons for this are not apparent from the present study.

Background: Acute pain is one of the most commonly cited reasons for attendance to the emergency department (ED), and the Royal College of Emergency Medicine (RCEM) Best Practice Guideline (2014) acknowledged that the current management of acute pain in UK EDs is inadequate and has a poor evidence base. Methods: The Prescription Of analgesia in Emergency Medicine (POEM) survey is a cross-sectional observational survey of consecutive patients presenting to 12 National Health Service (NHS) EDs with limb fracture and/or dislocation in England and Scotland and was carried out between 2015 and 2017. The primary outcome was to assess the adequacy of pain management in the ED against the recommendations in the RCEM Best Practice Guidelines. Results: In all 8346 patients were identified as attending the ED with a limb fracture and/or dislocation but adherence to RCEM guidelines could only be evaluated for the 4160 (49.8%) patients with a recorded pain score. Of these, 2409/4160 (57.9%) patients received appropriate pain relief, but only 1347 patients were also assessed within 20 minutes of their arrival in the ED. Therefore, according to the RCEM guidelines, only 16.1% (1347/8346) of all patients were assessed and had satisfactory pain management in the ED. Conclusions: The POEM survey has identified that pain relief for patients with an isolated limb fracture remains inadequate when strictly compared to the RCEM Best Practice Guidelines. However, we have found that some patients receive analgesia despite having no pain score recorded, while other analgesic modalities are provided that are not currently encompassed by the Best Practice Guidelines. Future iterations of these guidelines may wish to encompass the breadth of available modalities of pain relief and the whole patient journey. In addition, more work is needed to improve timely and repeated assessment of pain and its recording, which has been better achieved in some EDs than others.

Increased intracranial pressure (ICP) is an important cause of secondary brain injury and needs to be treated aggressively.1Marmarou A. Anderson R.L. Ward J.D. Choi S.C. Young H.F. Impact of ICP instability and hypotension on outcome in patients with severe head trauma.J Neurosurg. 1991; 75: S59-S66Crossref Scopus (640) Google Scholar The development of clinical protocols for the management of increased ICP has contributed to improved outcomes,2Patel H.C. Menon D.K. Tebbs S. Hawker R. Hutchinson P.J. Kirkpatrick P.J. Specialist neurocritical care and outcome from head injury.Intensive Care Med. 2002; 28: 547-553Crossref PubMed Scopus (294) Google Scholar, 3Clayton T.J. Nelson R.J. Manara A.R. Reduction in mortality from severe head injury following introduction of a protocol for intensive care management.Br J Anaesth. 2004; 93: 761-767Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar and whilst the gold standard for measurement of ICP is invasive, there are times when invasive devices are not available or are contraindicated. Invasive ICP methods also have inherent risks such as bleeding and infection, and as such a non-invasive method would be useful.4Robba C. Bacigaluppi S. Cardim D. Donnelly J. Bertuccio A. Czosnyka M. Non-invasive assessment of intracranial pressure.Acta Neurol Scand. 2016; 134: 4-21Crossref PubMed Scopus (80) Google Scholar Several methods have been studied to assess ICP non-invasively including transcranial Doppler ultrasound (TCD) and ultrasound measurement of optic nerve sheath diameter (ONSD).4Robba C. Bacigaluppi S. Cardim D. Donnelly J. Bertuccio A. Czosnyka M. Non-invasive assessment of intracranial pressure.Acta Neurol Scand. 2016; 134: 4-21Crossref PubMed Scopus (80) Google Scholar The latter technique has been shown to be well correlated with invasive ICP with good sensitivity and specificity.5Hansen H.C. Helmke K. Validation of the optic nerve sheath response to changing cerebrospinal fluid pressure: ultrasound findings during intrathecal infusion tests.J Neurosurg. 1997; 87: 34-40Crossref PubMed Scopus (317) Google Scholar, 6Eisenberg H.M. Gary H.E. Aldrich E.F. Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank.J Neurosurg. 1990; 73: 688-698Crossref PubMed Scopus (451) Google Scholar A recent study demonstrated that ultrasound assessment of ONSD is able to detect intracranial hypertension (ICP >20 mm Hg) [area under the curve (AUC), 0.91; 95% CI=0.88–0.95] with a sensitivity of 0.98 and a specificity of 0.64 for a threshold of 0.57 cm.7Robba C. Cardim D. Tajsic T. et al.Ultrasound non-invasive measurement of intracranial pressure in neurointensive care: a prospective observational study.PLoS Med. 2017; 14: e1002356Crossref PubMed Scopus (102) Google Scholar Similarly, several TCD-derived formulae including pulsatility index (PI) and a formula based on the flow velocity (nICPFVd) have also shown promise in the non-invasive assessment of ICP.8Rasulo F.A. Bertuetti R. Robba C. et al.The accuracy of transcranial Doppler in excluding intracranial hypertension following acute brain injury: a multicenter prospective pilot study. Traumatic intracranial hypertension.Crit Care. 2017; 21: 44Crossref PubMed Scopus (64) Google Scholar, 9Cardim D. Robba C. Bohdanowicz M. et al.Non-invasive monitoring of intracranial pressure using transcranial Doppler ultrasonography: is it possible?.Neurocrit Care. 2016; 25: 473-491Crossref PubMed Scopus (100) Google Scholar We recently successfully managed a case of raised intracranial pressure using the initial steps of our critical care unit raised ICP protocol (Supplementary material, Appendix S1) using non-invasive ICP (nICP) methods alone. A female in her 30s presented to the Emergency Department with fever, vomiting, and a reduced consciousness level [Glasgow Coma Scale (GCS) E1V2M5]. The patient was intubated, and treatment initiated for suspected meningitis. The head CT with contrast scan revealed cerebral oedema and extensive non-occlusive thrombus in the sagittal sinus, and she was also commenced on unfractionated heparin. Considering her ongoing high risk for intracranial hypertension, it was felt necessary to monitor her ICP to direct further therapy. Because she was receiving a heparin infusion, invasive ICP monitoring was relatively contraindicated. We therefore performed daily sedation holds for assessment of GCS and monitored her ICP non-invasively using repeated ultrasonographic assessments of ONSD, and estimated her ICP using PI and nICPFVd techniques. Ultrasound measurement was performed by a selected group of experienced operators using a standardised insonation technique to reduce inter-operator variability.7Robba C. Cardim D. Tajsic T. et al.Ultrasound non-invasive measurement of intracranial pressure in neurointensive care: a prospective observational study.PLoS Med. 2017; 14: e1002356Crossref PubMed Scopus (102) Google Scholar Ultrasound measurements were performed regularly every 4–6 h and whenever the clinician suspected significant changes in ICP with the patient in the supine position with the head of the bed elevated at 30°. During day 1–3 of her admission, ONSD was 4–5 mm (Fig. 1) and TCD revealed a PI <1 and nICPFVd <20 mm Hg with preserved autoregulation measured by the Mx index.10Czosnyka M. Smielewski P. Piechnik S. et al.Cerebral autoregulation following head injury.J Neurosurg. 2001; 95: 756-763Crossref PubMed Scopus (240) Google Scholar Three days after her admission, a sedation hold was performed and her best GCS recorded as E1VtM1. A repeat CT head scan showed a slight increase in the degree of brain swelling resulting in subtly increased narrowing of perimesencephalic cisterns only, and ONSD measured on CT was 7.1 mm compared with 4.6 mm measured on the initial CT.11Sekhon M.S. Griesdale D.E. Robba C. et al.Erratum to: optic nerve sheath diameter on computed tomography is correlated with simultaneously measured intracranial pressure in patients with severe traumatic brain injury.Intensive Care Med. 2015; 41: 177Crossref PubMed Scopus (6) Google Scholar ONSD values obtained were consistent with raised ICP (7.8 mm) (Fig. 1), and TCD showed a PI >2 and nICPFVd was >20 mm Hg with impaired autoregulation. We therefore escalated therapy, targeting ICP-lowering strategies to achieve ONSD <5.8 mm, PI <1.8 and nICPFVd <20 mm Hg. The patient was re-sedated and 100 ml 5% normal saline administered. Immediately after the administration of hypertonic saline, the ONSD was 5.4 mm, PI 1.4, and the nICPFVd had improved. Since the patient was being cared for on our ICP protocol, all haemodynamic parameters such as carbon dioxide partial pressure remained unchanged before and after hypertonic saline administration, and no other confounders such as patient position were present. The patient continued to be managed for the next 24 h on our ICP management protocol, receiving hypertonic saline boluses when ONSD was >5.8 mm. ONSD measurements remained <5.8 mm, PI <1.8, and nICPFVd <20 mm Hg. The sedation hold performed 24 h later revealed a much improved GCS (E1VtM6). The ICP protocol based on ONSD and TCD was gradually discontinued over the following 72 h, and the patient was successfully extubated. Whilst non-invasive methods have limitations including the need for specialised training, operator variability, and a temporal window not being present in up to 10–20% of patients,7Robba C. Cardim D. Tajsic T. et al.Ultrasound non-invasive measurement of intracranial pressure in neurointensive care: a prospective observational study.PLoS Med. 2017; 14: e1002356Crossref PubMed Scopus (102) Google Scholar, 8Rasulo F.A. Bertuetti R. Robba C. et al.The accuracy of transcranial Doppler in excluding intracranial hypertension following acute brain injury: a multicenter prospective pilot study. Traumatic intracranial hypertension.Crit Care. 2017; 21: 44Crossref PubMed Scopus (64) Google Scholar, 12Robba C. Cardim D. Donnelly J. et al.Effects of pneumoperitoneum and Trendelenburg position on intracranial pressure assessed using different non-invasive methods.Br J Anaesth. 2016; 117: 783-791Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar this case highlights that in the setting of impossible direct ICP measurement, a multimodal approach including clinical examination, nICP estimates, and CT scan findings can demonstrate a rising ICP. We have successfully used ONSD and TCD to estimate ICP for the first time as a target for the early steps of an ICP protocol. Non-invasive methods should not substitute for invasive ICP monitoring when indicated,4Robba C. Bacigaluppi S. Cardim D. Donnelly J. Bertuccio A. Czosnyka M. Non-invasive assessment of intracranial pressure.Acta Neurol Scand. 2016; 134: 4-21Crossref PubMed Scopus (80) Google Scholar but it is becoming increasingly clear that in certain cases when invasive methods are not immediately available or in borderline patients at risk of significant complications (haemorrhage, infection), non-invasive assessment can be a useful approach to guide management in the earlier, less aggressive stages of an ICP protocol. As prevention of pulmonary embolism in hospitalised patients increases, and the prevalence of patients on antiplatelet and anticoagulant medications increases, these techniques may have even broader applicability. We expect that with further research, the clinical application of these techniques will increase into the wider critical care environment. The authors declare that they have no conflicts of interest. 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A female patient in her 60s presented with a history of malaise, chills, headache and vomiting. She was in shock on presentation with a high haematocrit and a low albumin with evidence of rhabdomyolysis. Severe limb and truncal oedema developed with worsening hypotension leading to intensive care unit admission for multiple organ support. Extensive radiological, microbiological and immunological work up was negative with the exception of a monoclonal gammopathy. A review of patient investigations led to a diagnosis of Clarkson's disease. Treatment with high-dose methylprednisolone and intravenous immunoglobulins led to a rapid decline in the creatine kinase (CK) level and vasopressor requirements. The patient was discharged home on long-term terbutaline and has made a good recovery.