Reuben J. Strayer

Adverse events associated with ketamine for procedural sedation in adults

STUDY OBJECTIVES Ketamine is widely used as a procedural sedation agent in pediatrics, where its safety and efficacy are supported by numerous studies. Emergency physicians use ketamine infrequently in adults, as it is believed to have a more significant side effect profile in this population. However, adult data on ketamine use in the emergency medicine literature are sparse. Our objective was to determine ketamines adverse effect profile in adults when used for procedural sedation. METHODS We performed a literature review based on adverse effect research methodology recommendations. PubMed, EMBASE, TOXNET, and a variety of specialized databases were queried without regard to publication date or language. Experts were contacted to locate additional data. Inclusion criteria included adult study; ketamine used to facilitate the performance of painful procedures; dose of at least 1 mg/kg intravenous or at least 2 mg/kg intramuscular; original data and adverse events reported; spontaneously breathing patient, and no continuous cotherapies. Studies that met inclusion criteria were abstracted onto structured forms and their results qualitatively summarized. RESULTS Of the 5512 unique citations that were evaluated, 87 met criteria for inclusion. Most studies were performed in the 1970s and published in the anesthesia literature. Contexts, end points, and methodological quality varied widely across studies. Ketamine reliably produces conditions that facilitate the performance of painful procedures. Pharyngeal reflexes are generally preserved and cardiovascular tone stimulated, including a rise in blood pressure and myocardial oxygen demand. Laryngospasm and airway obstruction are reported, and though ketamine is a respiratory stimulant, a brief period of apnea around the time of injection is common. Reports of significant cardiorespiratory adverse events are rare, despite ketamines frequent use in austere, poorly monitored settings. Dysphoric emergence phenomena occur in 10% to 20% of cases; sedating medications are effective in preventing and managing these reactions. CONCLUSION When ketamine is used for procedural sedation in adults, emergence phenomena occur in 10% to 20% of patients. Although providers must be prepared to recognize and manage airway obstruction, cardiorespiratory adverse events are rare and typically do not affect outcomes.

Screening, Evaluation, and Early Management of Acute Aortic Dissection in the ED

Acute aortic dissection (AAD) is a rare and lethal disease with presenting signs and symptoms that can often be seen with other high risk conditions; diagnosis is therefore often delayed or missed. Pain is present in up to 90% of cases and is typically severe at onset. Many patients present with acute on chronic hypertension, but hypotension is an ominous sign, often reflecting hemorrhage or cardiac tamponade. The chest x-ray can be normal in 10-20% of patients with AAD, and though transthoracic echocardiography is useful if suggestive findings are seen, and should be used to identify pericardial effusion, TTE cannot be used to exclude AAD. Transesophageal echocardiography, however, reliably confirms or excludes the diagnosis, where such equipment and expertise is available. CT scan with IV contrast is the most common imaging modality used to diagnose and classify AAD, and MRI can be used in patients in whom the use of CT or IV contrast is undesirable. Recent specialty guidelines have helped define high-risk features and a diagnostic pathway that can be used the emergency department setting. Initial management of diagnosed or highly suspected acute aortic dissection focuses on pain control, heart rate and then blood pressure management, and immediate surgical consultation.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial.

To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.

A conceptual framework for improved analyses of 72-hour return cases

For more than 25 years, emergency medicine researchers have examined 72-hour return visits as a marker for high-risk patient visits and as a surrogate measure for quality of care. Individual emergency departments frequently use 72-hour returns as a screening tool to identify deficits in care, although comprehensive departmental reviews of this nature may consume considerable resources. We discuss the lack of published data supporting the use of 72-hour return frequency as an overall performance measure and examine why this is not a valid use, describe a conceptual framework for reviewing 72-hour return cases as a screening tool, and call for future studies to test various models for conducting such quality assurance reviews of patients who return to the emergency department within 72 hours.

Something for pain: Responsible opioid use in emergency medicine

&NA; The United States is currently experiencing a public health crisis of opioid addiction, which has its genesis in an industry marketing effort that successfully encouraged clinicians to prescribe opioids liberally, and asserted the safety of prescribing opioids for chronic non‐cancer pain, despite a preponderance of evidence demonstrating the risks of dependence and misuse. The resulting rise in opioid use has pushed drug overdose deaths in front of motor vehicle collisions to become the leading cause of accidental death in the country. Emergency providers frequently treat patients for complications of opioid abuse, and also manage patients with acute and chronic pain, for which opioids are routinely prescribed. Emergency providers are therefore well positioned to both prevent new cases of opioid misuse and initiate appropriate treatment of existing opioid addicts. In opioid‐naive patients, this is accomplished by a careful consideration of the likelihood of benefit and harm of an opioid prescription for acute pain. If opioids are prescribed, the chance of harm is reduced by matching the number of pills prescribed to the expected duration of pain and selecting an opioid preparation with low abuse liability. Patients who present to acute care with exacerbations of chronic pain or painful conditions associated with opioid misuse are best managed by treating symptoms with opioid alternatives and encouraging treatment for opioid addiction.

Independent Dosing of Propofol and Ketamine May Improve Procedural Sedation Compared With the Combination “Ketofol”

To the Editor: In their recent article on ketofol, Andolfatto et al demonstrate that this combination medication appears no safer than propofol alone. However, more consideration is merited for the strategy of using propofol and ketamine together for the initial sedation administration, followed by propofol monotherapy for subsequent boluses. The pharmacodynamics of ketamine requires 30 to 120 minutes of monitoring after administration compared with a maximum of 10 to 15 minutes for propofol. Because of this substantially longer duration of effect, it is illogical to redose the ketamine component of ketofol near the end of a lengthy procedure when propofol alone would suffice. Furthermore, ketamine appears to dissociate patients in a dichotomous manner, meaning that providing small additional boluses of the drug to already dissociated patients may provide zero clinical benefit. These concerns about the coadministration of the 2 agents have been suggested before, yet most emergency medicine investigations of ketofol nevertheless have studied the combined formulation. We believe that independent dosing of the 2 drugs is superior to the combined dosing, but it may also be superior to propofol alone. As the data suggest from this most recent article by Andolfatto et al, ketamine may provide patients with an increased sedation consistency versus providers’ having to rely solely on intermittent doses of propofol. We hope that further studies may demonstrate that separating the administration of these 2 agents can provide the sedation consistency of ketamine with the rapid recovery time inherent with propofol boluses.

A novel program to improve patient safety by integrating peer review into the emergency medicine residency curriculum.

BACKGROUND Evaluating the quality of care as part of a quality improvement process is required in many clinical environments by accrediting bodies. It produces metrics used to evaluate department and individual provider performance, provides outcomes-based feedback to clinicians, and identifies ways to reduce error. DISCUSSION To improve patient safety and train our residents to perform peer review, we expanded our quality assurance program from a narrow, administrative process carried out by a small number of attendings to an educationally focused activity of much greater scope incorporating all residents on a monthly basis. We developed an explicit system by which residents analyze sets of high-risk cases and record their impressions onto structured databases, which are reviewed by faculty. At monthly meetings, results from the months case reviews are presented, learning points discussed, and corrective actions are proposed. CONCLUSION By integrating Clinical Quality Review (CQR) as a core, continuous component of the residency curriculum, we increased the number of cases reviewed more than 10-fold and implemented a variety of clinical process improvements. An anonymous survey conducted after 2 years of resident-led CQR indicated that residents value their exposure to the peer review process and feel it benefits them as clinicians, but also that the program requires a significant investment of time that can be burdensome.

Rocuronium vs. Succinylcholine Revisited

ith infection and resource overutilization. It is possible hat blood transfusion in retrospective studies using mulivariate analysis was just a surrogate for severe injuries nd prolonged shock, and therefore, the risk of infection as increased due to ischemia and reperfusion, and overhelming inflammation. Zink et al. also examined in heir study the potential harm of transfusion-induced ung dysfunction and Acute Respiratory Distress Synrome (13). They found no difference in respiratory utcomes based on PRBCs:FFP ratios. Interestingly, repiratory outcomes improved with higher PRBCs:plateet ratios. Finally, Drs. Devlin and Gutierrez mentioned the isue of resource utilization. O’Keeffe et al. demonstrated hat having a well-defined massive transfusion protocol ecreased the overall blood product usage and cost (14). The Iraqi and Enduring Freedom conflicts have solidfied the paradigm that not all transfusion strategies are qual. Despite the lack of randomized, prospective civilan trials (one is being launched soon), it is important to e cognizant that bleeding patients are also not equal. apid identification of the bleeding injured patient and mmediate intervention to improve tissue perfusion and o correct the trauma-induced coagulopathy would cerainly offer the best chance for survival.

Bedside Ultrasound to Evaluate Pulmonary Embolism Masquerading as ST Elevation Myocardial Infarction (STEMI).

We present a case highlighting the use of bedside ultrasound to aid in the diagnosis of pulmonary embolism (PE). This patient had chest pain and electrocardiogram (ECG) findings that seemed otherwise consistent with ST elevation myocardial infarction (STEMI); ultrasound was instrumental in his diagnosis and subsequent treatment. The frequent similarities in presentation of these two diseases are well described. Several relevant studies have shown how bedside ultrasound can evaluate undifferentiated shock and suggest PE in cases such as this.

Fatal Pulmonary Embolization after Negative Serial Ultrasounds

BACKGROUND Isolated distal deep vein thrombosis (DVT) is not traditionally viewed as a potentially life-threatening condition. There are conflicting recommendations regarding its evaluation and treatment, and wide variability in clinical practice. The presentation of this case highlights the fatal potential of this condition. CASE REPORT This is the report of a previously healthy young woman who presented to the emergency department with calf pain concerning for a DVT. She received two radiologist-performed duplex ultrasound examinations of the affected extremity, both of which were negative, but suffered a sudden cardiac arrest several hours after the second study. Autopsy attributed the death to DVT and pulmonary embolism. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the risk for fatal pulmonary embolization, even after normal serial ultrasound examinations to exclude DVT.