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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.

Glass Foreign Body in Soft Tissue: Possibility of High Morbidity Due to Delayed Migration

BACKGROUND Soft tissue foreign bodies (FBs) are a common occurrence in emergency departments (EDs). Some FBs cause complications, whereas others are asymptomatic and remain undetected for months or years. CASE REPORT A 32-year-old man presented to the ED with complaints of back pain in the area of a subcutaneous lump that had migrated toward the midline, nearly 25 cm from its former location, over the previous 2 weeks. Twelve years previously, after falling onto a glass door that shattered, he had gone to a local ED and had his wound sutured, but no X-ray studies were taken. Within a few months, he noticed a lump near his scapula, but he did not relate it to the fall and it did not bother him much. Physical examination revealed a normal neurological examination and a palpable mass in the right paraspinal area at the level of the tenth thoracic vertebra. An X-ray study showed a 34-mm-long sharp density in the vicinity of the spinal canal near T10. Efforts lasting almost 2 h to identify and remove the foreign body were unsuccessful. The following day, a 4 × 6 × 34 mm sharp glass fragment was removed in the operating room under fluoroscopy. CONCLUSIONS Retained soft-tissue foreign bodies may migrate very late and can cause high morbidity or mortality. It is important to be diligent in the search for foreign bodies, using ultrasound, computed tomography scan, or magnetic resonance imaging in cases in which initial plain radiographs are negative.

Agreement between axillary, tympanic, and mid-forehead body temperature measurements in adult emergency department patients.

Objective To assess the agreement between noncontact infrared thermometer (noncontact) with infrared tympanic thermometer (tympanic) and electronic axillary thermometer (axillary) in an adult emergency department population. Materials and methods This is a single-center, cross-sectional, prospective trial carried out in a Joint Commission accredited private hospital in Turkiye. All consecutive patients above 16 years were included in the study. The agreements between three methods were analyzed by Bland–Altman analysis with MedCalc 11.0.4 statistical software. Results Body temperatures were measured on 400 patients (48% were men, mean 35.9±17.3°C). Mean noncontact, tympanic, and axillary measurements (±SD) were 37.22±1.03, 36.72±0.95, and 36.91±0.96°C, respectively, whereas Intraclass Correlation Coefficient of all measurements was 0.892 (95% confidence interval 0.821–0.929). Binary comparisons between body temperature measurements produced mean differences &Dgr; axillary−tympanic, &Dgr; axillary−noncontact, and &Dgr; tympanic−noncontact as 0.5±0.63, 0.2±0.71, and 0.31±0.61°C, respectively. However, the agreement limits for axillary and noncontact was between −1.2 and 1.6°C; −1.74 and 0.74°C for tympanic and noncontact, and −1.52 and 0.9°C for tympanic and noncontact. Conclusion There is a lack of agreement between body temperature measurements by noncontact, tympanic, and axillary in the adult emergency department population. The easy application may lead noncontact to be the preferable method for healthcare providers but large agreement limits should be considered.

Value of the timing of informing the emergency department patients on cardiac test results: a randomized controlled study.

Objective This study is designed to investigate the role of written information, and the value of its timing, provided to Emergency Department (ED) patients regarding cardiac enzyme tests (CET), on their personal concerns about their health status and their discussions with the emergency physicians as to their normal health status post-test. Materials and methods This is a prospective randomized controlled study. All consecutive patients used for this study were admitted to the university-based ED within the 6-month study period with the presenting chief complaint of atypical chest pain, which was considered as the presumptive diagnosis. CET was ordered to rule out acute coronary syndromes, and these patients were enrolled into the study groups. Results The study sample included 523 patients whose CET were ordered and who were therefore eligible for the study. Three groups were similar in terms of persuasion and anxiety scores. Groups, which were informed about the test by leaflet had lower anxiety and persuasion scores. The lowest anxiety scores were found especially in the group in which the information was given before CET was drawn (P<0.001). The effects of monitoring on patients and providing information with a leaflet were found significant on reassurance scores (P=0.006, P<0.001). Reassurance scores of the patients on whom at least one of the procedures, for example, monitoring, more than one electrocardiogram and chest radiograph, had been carried out, showed significant difference compared with those on whom neither of these procedures had been done during the ED observation (P=0.001). Conclusion Written information provided to patients undergoing cardiac tests in ED population was found effective on anxiety and persuasion scores.