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The first direct comparison of the Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar) scale to a slightly modified Richmond Agitation and Sedation Scale (mRASS-AW) in a pre-post quality assurance study found mRASS-AW to not compromise length of stay or safety for the evaluation of alcohol withdrawal syndrome (AWS), while we already know it to be faster and more intuitive.

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Replacing the Clinical Institute Withdrawal Assessment-Alcohol revised with the modified Richmond Agitation and Sedation Scale for alcohol withdrawal to support management of alcohol withdrawal symptoms: potential impact on length of stay and complications. CJEM. 2024;26(6):431-435. doi:10.1007/s43678-024-00710-7

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GRACE-4 is packed with practice-changing recommendations for patients with alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS).

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Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4): Alcohol use disorder and cannabinoid hyperemesis syndrome management in the emergency department. Acad Emerg Med. 2024 May;31(5):425-455. doi: 10.1111/acem.14911. PMID: 38747203.

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A retrospective study of 60 patients who received a fixed-dose ketamine of 250 mg by EMS observed that 6 were intubated in the ED. There was no association between weight-based dose of ketamine and risk for intubation.

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Fixed dose ketamine for prehospital management of hyperactive delirium with severe agitation. Am J Emerg Med. Published online April 9, 2024. doi:10.1016/j.ajem.2024.04.011

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This systematic review was conducted to answer the clinical question: Is there a superior parenteral medication or combination of medications for acute management of adult out-of-hospital or emergency department patients with severe agitation? These recommendations do not apply to pediatric, elderly (>65 years), pregnant, or out-of-hospital patients.  For these groups, additional studies are needed given unique risk profiles.

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Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation: Approved by the ACEP Board of Directors, October 6, 2023. Ann Emerg Med. 2024 Jan;83(1):e1-e30. doi: 10.1016/j.annemergmed.2023.09.010. PMID: 38105109.

Please read this announcement about upgrades to JournalFeed (CME, Amal Mattu, new website)! We also need to do a price increase due to rising costs. Price changes started Dec. 1, 2023 for new subscribers and on Jan 1, 2024 for current subscriber auto-renewals. If cost is a barrier for you, please read the announcement. We want to help! ~Clay Smith

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This systematic review and meta-analysis did not show significant improvement in measured patient outcomes for treatment of alcohol withdrawal syndrome with phenobarbital vs benzodiazepines.

Source
Phenobarbital Treatment of Alcohol Withdrawal in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2023 Nov 3. doi: 10.1111/acem.14825. Online ahead of print.

Please read this announcement about upgrades to JournalFeed (CME, Amal Mattu, new website)! We also need to do a price increase due to rising costs. Price changes started Dec. 1, 2023 for new subscribers and on Jan 1, 2024 for current subscriber auto-renewals. If cost is a barrier for you, please read the announcement. We want to help! ~Clay Smith

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Catatonia is a psychiatric condition with variable and unpredictable clinical features. Let's dive into how to recognize, diagnose, and manage it in the ED.

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This cohort study of 1.8 million US healthcare workers (HCWs) found that registered nurses, health technicians, and health care support workers in the US were at increased risk of suicide relative to non-HCWs.

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Suicide Risks of Health Care Workers in the US. JAMA vol. 330,12 (2023): 1161-1166. doi:10.1001/jama.2023.15787

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Personality disorders are common and complex emotional difficulties that are challenging to identify, categorize, and manage. Language surrounding these often-stigmatized diagnoses is changing, as are the recommendations on treatment of individuals with personality disorders.

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Depression screening (with varying forms of intervention) reduces depression symptoms in follow up, and the screening tools are fairly accurate. Suicide screening (with various interventions) does not reduce suicidal ideation or suicide attempts and may actually increase attempts, though the evidence is very limited.

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Depression and Suicide Risk Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2023 Jun 20;329(23):2068-2085. doi: 10.1001/jama.2023.7787.

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From 2011 to 2020, the number of mental health visits in pediatric EDs increased from 7.7% to 13.1% of all encounters, with a significant increase in the proportion of suicide-related visits.

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National Trends in Mental Health-Related Emergency Department Visits Among Youth, 2011-2020. JAMA. 2023 May 2;329(17):1469-1477. doi: 10.1001/jama.2023.4809.