Cenker Eken

Ketamine With and Without Midazolam for Emergency Department Sedation in Adults: A Randomized Controlled Trial

STUDY OBJECTIVE We assess whether midazolam reduces recovery agitation after ketamine administration in adult emergency department (ED) patients and also compared the incidence of adverse events (recovery agitation, respiratory, and nausea/vomiting) by the intravenous (IV) versus intramuscular (IM) route. METHODS This prospective, double-blind, placebo-controlled, 2×2 factorial trial randomized consecutive ED patients aged 18 to 50 years to 4 groups: receiving either 0.03 mg/kg IV midazolam or placebo, and with ketamine administered either 1.5 mg/kg IV or 4 mg/kg IM. Adverse events and sedation characteristics were recorded. RESULTS Of the 182 subjects, recovery agitation was less common in the midazolam cohorts (8% versus 25%; difference 17%; 95% confidence interval [CI] 6% to 28%; number needed to treat 6). When IV versus IM routes were compared, the incidences of adverse events were similar (recovery agitation 13% versus 17%, difference 4%, 95% CI -8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI -2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI -8% to 20%). CONCLUSION Coadministered midazolam significantly reduces the incidence of recovery agitation after ketamine procedural sedation and analgesia in ED adults (number needed to treat 6). Adverse events occur at similar frequency by the IV or IM routes.

Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial.

STUDY OBJECTIVE This randomized, placebo-controlled trial evaluates the analgesic efficacy and safety of intravenous single-dose paracetamol and morphine for the treatment of renal colic. METHODS We conducted a randomized, double-blind, placebo-controlled clinical trial comparing single intravenous doses of paracetamol (1 g), morphine (0.1 mg/kg), and placebo (normal saline solution) for patients presenting to the emergency department (ED) with suspected renal colic. Subjects with inadequate pain relief at 30 minutes received rescue fentanyl (0.75 microg/kg). We compared changes in pain intensity 30 minutes after treatment among the 3 arms, as well as the need for rescue medication and the presence of adverse effects. RESULTS Six hundred forty-five consecutive patients were screened for study and 165 were entered. Eight subjects were subsequently excluded from analysis because of protocol violations and 11 were excluded because of uncertain diagnoses, leaving 146 subjects available for analysis. The mean reduction in visual analogue scale pain intensity scores at 30 minutes was 43 mm for paracetamol (95% confidence interval [CI] 35 to 51 mm), 40 mm for morphine (95% CI 29 to 52 mm), and 27 mm for placebo (95% CI 19 to 34 mm). Statistically significant mean differences in pain intensity reductions compared with those for placebo were observed for paracetamol (16; 95% CI 5 to 27; P=.005) and morphine (14; 95% CI 0.4 to 27; P=.05); however, no difference was found between paracetamol and morphine (2; 95% CI -13 to 16; P=.74). Rescue analgesics at 30 minutes were required by 21 subjects (45%) receiving paracetamol, 24 subjects (49%) receiving morphine, and 34 subjects (67%) receiving placebo (P=.08). At least 1 adverse effect was experienced by 11 (24%) receiving paracetamol, 16 (33%) receiving morphine, and 8 (16%) in the placebo group (P=.14). There were no serious adverse events. CONCLUSION Intravenous paracetamol is an efficacious and safe treatment for ED patients with renal colic.

Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blind controlled trial

Objective To determine the analgesic efficacy and safety of intravenous single-dose paracetamol versus morphine in patients presenting to the emergency department with renal colic. Methods A randomised double-blind study was performed to compare the efficacy of intravenous paracetamol (1 g) and 0.1 mg/kg morphine in patients with renal colic. The efficacy of the study drugs was measured by a visual analogue scale and a verbal rating scale at baseline and after 15 and 30 min. The adverse effects and need for rescue medication (1 μg/kg intravenous fentanyl) were also recorded at the end of the study. Results 133 patients were eligible for enrolment in the study, with 73 patients included in the final analysis (38 in the paracetamol group and 35 in the morphine group). The mean±SD age of the subjects was 30.2±8.6 years and 51 (70%) were men. The mean reduction in scores at 30 min after study drug administration was 63.7 mm (95% CI 57 to 71) for paracetamol and 56.6 mm (95% CI 48 to 65) for morphine. The difference between pain reduction scores for the two groups at 30 min was 7.1 mm (95% CI −18 to 4), demonstrating no statistical or clinical significance. Two adverse events (5.3%) were recorded in the paracetamol group and five (14.3%) in the morphine group (difference 9%, 95% CI −7% to 26%). Conclusion Intravenous paracetamol is effective in treating patients presenting with renal colic to the emergency department. Clinical trials registration no ClinicalTrials.gov ID number NCT01318187.

Anxiety and Depressive Disorders in Patients Presenting with Chest Pain to the Emergency Department: A Comparison Between Cardiac and Non-Cardiac Origin

OBJECTIVE The aim of this study was to determine the prevalence of anxiety and depressive disorders in patients presenting with chest pain to the Emergency Department (ED) and determine if there is a relationship between these and cardiac vs. non-cardiac chest pain. METHODS This prospective cross-sectional study was performed in an urban tertiary care hospital between March and October 2005. Consecutive patients presenting with chest pain were enrolled in the study. The prevalence of anxiety and depressive disorders in patients with chest pain were determined by using the Hospital Anxiety and Depression Scale. RESULTS A total of 324 patients presented to the ED with chest pain during the study period. The mean age of the patients studied was 50.5 +/- 14 years; 67% were men and 33% were women. Of the 324 study patients, 194 (59.9%) patients were diagnosed with non-cardiac chest pain, 16 (4.9%) with stable angina, 84 (25.9%) with unstable angina, and 30 (9.3%) with acute myocardial infarction. No statistically significant differences were determined between patients with cardiac and non-cardiac chest pain both for anxiety (40% vs. 38.1%, respectively; p = 0.737) and depressive disorders (52.3% vs. 52.1%, respectively; p = 0.965). CONCLUSION Anxiety and depressive disorders are common among patients presenting with chest pain to the ED. However, the prevalence of anxiety and depressive disorders is similar between patients with chest pain of cardiac and non-cardiac origin. Chest pain should not be attributed to an anxiety or depressive disorder before organic etiologies are excluded.

Comparison of the Full Outline of Unresponsiveness Score Coma Scale and the Glasgow Coma Scale in an emergency setting population.

Background The Glasgow Coma Scale (GCS) is the most widely used tool for the evaluation of the level of consciousness. The Full Outline of Unresponsiveness (FOUR) Score is a new coma Scale that was developed considering the limitations of the GCS, and has been found to be useful in an intensive care setting. We aimed to compare FOUR Score and GCS in the emergency setting. Methods All patients older than 17 years who presented with an altered level of consciousness, after any trauma to the head or with neurological complaints were included in this study. Three-month mortality, in-hospital mortality, and poor outcome using a Modified Rankin Scale (MRS) of 3–6 points were used as the primary outcome measures. Results A total of 185 patients were included in the study. Area under the curve (AUC) values in predicting 3-month mortality for GCS was 0.726 [P=0.0001 and 95% confidence interval (CI): 0.656–0.789] and 0.776 (P=0.0001 and 95% CI: 0.709–834) for FOUR Score. AUC in predicting hospital mortality for GCS was 0.735 (P=0.0001 and 95% CI: 0.655–0.797) and 0.788 (P=0.0001 and 95% CI: 0.722–0.844) for FOUR Score. AUC in predicting poor outcome (Modified Rankin Scale: 3–6) was 0.720 (P=0.001 and 95% CI: 0.650–784) for GCS and 0.751 (P=0.0001 and 95% CI: 0.682–0.812) for FOUR Score. Conclusion The new coma Scale, FOUR Score, is not superior to the GCS. However, the combination of the eye and motor components of FOUR Score is a valuable tool that can be used instead of either the FOUR Score or GCS.

ETco2: a predictive tool for excluding metabolic disturbances in nonintubated patients

OBJECTIVES The purpose of this study is to examine the relation between end-tidal carbon dioxide (ETCO₂) measurement and bicarbonate (HCO₃) level reflecting the patients metabolic status. METHOD This prospective cross-sectional study has been carried out during a 3-month period in a tertiary care university hospitals emergency department (ED). During the study period, every spontaneously ventilating ED patient requiring arterial blood gas analysis for any medical indication, regardless of presenting symptoms, had a simultaneous ETCO₂ measurement using a Medlab Cap 10 side stream capnograph. The demographics and clinical outcomes of the patients were recorded. RESULTS Of 399 eligible patients, 240 with possible metabolic disturbance were enrolled into the study. There was a statistically significant correlation between the value of ETCO₂ and HCO₃ levels (r = 0.506). The mean ET(CO)₂ level was statistically significantly lower in patients who died (26.5 ± 7.2, 95% confidence interval [CI], 24.2-28.6, vs 30 ± 7.5, 95% CI, 29-31; P = .007) and who had low bicarbonate levels (25.7 ± 6.7, 95% CI, 24.3-27.1, vs 31.6 ± 7.1, 95% CI, 30.4-32.8; P = .000). The value of ET(CO)₂ measurement to detect low bicarbonate level was found to be significant. The area under the receiver operating characteristic curve was 0.734, the (+) likelihood ratio for ETCO₂ less than or equal to 25 was 2.7, and the (-) likelihood ratio for ETCO₂ greater than or equal to 36 was 0.05. CONCLUSION ETCO₂ values correlate moderately with HCO₃ levels and thus might predict mortality and metabolic acidosis. Therefore, side stream capnograph can be used as a noninvasive diagnostic tool for ruling out suspected severe metabolic disturbance in the ED.

Intravenous paracetamol versus dexketoprofen in acute migraine attack in the emergency department: a randomised clinical trial.

Objective Migraine is a common form of headache that is a major burden for patients who often seek emergency care. The goal of this study was to compare the effectiveness of intravenous non-steroidal anti-inflammatory medication (dexketoprofen) with paracetamol (acetaminophen) in the treatment of an acute migraine attack. Materials and methods This prospective, randomised, double blind, controlled study was conducted in a tertiary care emergency unit. Study patients were randomised into two groups to receive either 50 mg of dexketoprofen trometamol or 1000 mg of paracetamol intravenously by rapid infusion in 150 mL of normal saline. Pain reduction was measured at baseline, and after 15 and 30 min, using a Visual Analogue Scale (VAS)) as the primary outcome. VAS is a measurement tool ranging from 0 (no pain) to 100 mm (worst pain). Results 200 patients were included in the final analysis. Mean (SD) age of the study subjects was 30.1±11 years and 81% (n=162) were women. Median reduction in VAS score at 30 min was 56 (IQR 30–78.5) for the paracetamol group and 55 (IQR 34–75) for the dexketoprofen group, with a difference of 1 mm (95% CI −7 to 10) between the two groups. Conclusions Intravenous paracetamol and dexketoprofen appear to produce equivalent pain relief for migraine in the emergency department. ClinicalTrials.gov No NCT01730326.

Intravenous paracetamol versus dexketoprofen versus morphine in acute mechanical low back pain in the emergency department: a randomised double-blind controlled trial

Study objective The objective of this study was to determine the analgesic efficacy and safety of intravenous, single-dose paracetamol versus dexketoprofen versus morphine in patients presenting with mechanical low back pain (LBP) to the emergency department (ED). Methods This randomised double-blind study compared the efficacy of intravenous 1 gm paracetamol, 50 mg dexketoprofen and 0.1 mg/kg morphine in patients with acute mechanical LBP. Visual analogue scale (VAS) was used for pain measurement at baseline, after 15 and after 30 min. Results A total of 874 patients were eligible for the study, and 137 of them were included in the final analysis: 46 patients from the paracetamol group, 46 patients in the dexketoprofen group and 45 patients in the morphine group. The mean age of study subjects was 31.5±9.5 years, and 60.6% (n=83) of them were men. The median reduction in VAS score at the 30th minute for the paracetamol group was 65 mm (95% CI 58 to 72), 67 mm (95% CI 60 to 73) for the morphine group and 58 mm (95% CI 50 to 64) for the dexketoprophen group. Although morphine was not superior to paracetamol at 30 min (difference: 3.8±4.9 (95% CI −6 to 14), the difference between morphine and dexketoprofen in reducing pain was 11.2±4.7 (95% CI 2 to 21). At least one adverse effect occurred in 8.7% (n=4) of the cases in the paracetamol group, 15.5% (n=7) of the morphine group, and 8.7% (n=4) of the dexketoprophen group (p=0.482). Conclusions Intravenous paracetamol, dexketoprofen and morphine are not superior to each other for the treatment of mechanical LBP in ED.

Nine cases of nonpalpable testicular mass: an incidental finding in a large scale ultrasonography survey

Objectives:  Nonpalpable testicular masses are usually diagnosed during routine ultrasonography (US) examinations for other conditions. There are conflicting results on the final diagnosis and management of these lesions. In the present study we report the results of a large US series of 5104 patients on nonpalpable testicular masses and discuss the management of these patients.

Are YouTube videos accurate and reliable on basic life support and cardiopulmonary resuscitation

The objective of this study is to investigate reliability and accuracy of the information on YouTube videos related to CPR and BLS in accord with 2010 CPR guidelines.