Joseph D. Losek

Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children

STUDY OBJECTIVE Although ketamine is one of the most commonly used sedatives to facilitate painful procedures for children in the emergency department (ED), existing studies have not been large enough to identify clinical factors that are predictive of uncommon airway and respiratory adverse events. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regressions to determine which clinical variables would predict airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of airway and respiratory adverse events was 3.9%, with the following significant independent predictors: younger than 2 years (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.47 to 2.72), aged 13 years or older (OR 2.72; 95% CI 1.97 to 3.75), high intravenous dosing (initial dose > or =2.5 mg/kg or total dose > or =5.0 mg/kg; OR 2.18; 95% CI 1.59 to 2.99), coadministered anticholinergic (OR 1.82; 95% CI 1.36 to 2.42), and coadministered benzodiazepine (OR 1.39; 95% CI 1.08 to 1.78). Variables without independent association included oropharyngeal procedures, underlying physical illness (American Society of Anesthesiologists class >or = 3), and the choice of intravenous versus intramuscular route. CONCLUSION Risk factors that predict ketamine-associated airway and respiratory adverse events are high intravenous doses, administration to children younger than 2 years or aged 13 years or older, and the use of coadministered anticholinergics or benzodiazepines.

Predictors of Emesis and Recovery Agitation With Emergency Department Ketamine Sedation: An Individual-Patient Data Meta-Analysis of 8,282 Children

STUDY OBJECTIVE Ketamine is widely used in emergency departments (EDs) to facilitate painful procedures; however, existing descriptors of predictors of emesis and recovery agitation are derived from relatively small studies. METHODS We pooled individual-patient data from 32 ED studies and performed multiple logistic regression to determine which clinical variables would predict emesis and recovery agitation. The first phase of this study similarly identified predictors of airway and respiratory adverse events. RESULTS In 8,282 pediatric ketamine sedations, the overall incidence of emesis, any recovery agitation, and clinically important recovery agitation was 8.4%, 7.6%, and 1.4%, respectively. The most important independent predictors of emesis are unusually high intravenous (IV) dose (initial dose of > or =2.5 mg/kg or a total dose of > or =5.0 mg/kg), intramuscular (IM) route, and increasing age (peak at 12 years). Similar risk factors for any recovery agitation are low IM dose (<3.0 mg/kg) and unusually high IV dose, with no such important risk factors for clinically important recovery agitation. CONCLUSION Early adolescence is the peak age for ketamine-associated emesis, and its rate is higher with IM administration and with unusually high IV doses. Recovery agitation is not age related to a clinically important degree. When we interpreted it in conjunction with the separate airway adverse event phase of this analysis, we found no apparent clinically important benefit or harm from coadministered anticholinergics and benzodiazepines and no increase in adverse events with either oropharyngeal procedures or the presence of substantial underlying illness. These and other results herein challenge many widely held views about ED ketamine administration.

Temporal Artery Thermometry Utilization in Pediatric Emergency Care

Objective To determine the effectiveness of temporal artery thermometry (TAT) as an alternative for temperature assessment of children 1 to 4 years of age in the pediatric emergency department. Methods Prospective cross-sectional study conducted at an urban childrens hospital emergency department. TAT and rectal temperatures are compared in a convenience sample of children 1 to 4 years of age. Comparison of the temperatures is performed using Pearson correlation coefficient and regression analysis. Results TAT and rectal temperatures are measured in 42 children 1 to 4 years of age. TAT predicts 83% of rectal temperatures. A receiver operating characteristic curve analysis shows that a cutoff of 37.7°C or greater for fever in TAT is equivalent to rectal temperature greater than or equal to 38.3°C with 100% sensitivity and 93.5% specificity. Conclusion TAT is an effective screening tool in identifying fever in children 1 to 4 years of age.

Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED.

BACKGROUND Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes. OBJECTIVES We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets. METHODS We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates. RESULTS There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value < .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value < .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates. CONCLUSIONS An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock.

Successful flumazenil reversal of paradoxical reaction to midazolam in a child.

BACKGROUND Greater attention to and management of anxiety and pain in pediatric patients signifies a healthy evolution in the care of children in emergency departments (EDs). Interventions to address such distress may involve unanticipated adverse effects. Midazolam, a benzodiazepine commonly administered to children for anxiolysis, may precipitate paradoxical agitation and delirium, a rare but alarming effect that warrants prompt identification and treatment. CASE REPORT The case presented is that of a 4-year-old girl who received oral midazolam and developed a paradoxical reaction, which was reversed successfully with flumazenil. This is the first such case report in an ED involving a child. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must stay abreast of the adverse and unintended effects of the treatments provided. The literature on benzodiazepine-induced paradoxical reactions is reviewed, and flumazenil as well as other treatment options and anxiolytic alternatives are presented.

Clinical effectiveness of bougienage for esophageal coins in a pediatric ED

OBJECTIVE To describe a tertiary care pediatric emergency department (PED) experience with bougienage for esophageal coins. METHODS This was a large retrospective case series of children with esophageal coins presenting to a tertiary PED from January 2004 to October 2012. Bougienage eligibility criteria were medically stable, no prior gastro-esophageal surgery or disease, single coin, and witnessed ingestion within 24 hours. Abstracted data were age, signs and symptoms, coin type, management, efficacy, complications, returns, length of stay (LOS), and hospital charges. Main outcomes included procedural success and complications. Secondary outcomes included LOS and hospital charges. RESULTS There were 245 patients with esophageal coins with 136/145 (94%) successful bougienage procedures and 109/109 (100%) successful surgical retrievals. There were 18 minor complications and 5 return visits for patients with bougienage. There were 10 minor and 2 major complications with surgical retrieval. Patients undergoing bougienage were 4 years (SD 2) vs 3 years (SD 3) for surgical retrieval (P < 0.001). Mean LOS for successful bougienage was 137 minutes (SD 54) vs 769 (SD 535) for surgical retrieval. The difference in the means was 632, 95% CI for the difference in means of -723 to -541 (P < .001). Mean charges for successful bougienage were

Hyperglycaemic hyperosmolar syndrome in children: Patient characteristics, diagnostic delays and associated complications.

984 (SD

Effectiveness of a Medicolegal Lecture on Risk-Reduction Medical Record Documentation by Pediatric Residents

576) vs.

Disseminated Salmonella Osetomyelitis in a 2-Year-Old With Sickle Cell Disease

7022 (SD

Anisocoria and Topical Carbamate Exposure: Illustrative Case Report

3132) for surgical retrieval. The difference in means was