T. Kent Denmark

Ketamine sedation for pediatric critical care procedures

Objectives To describe our experience using ketamine sedation to facilitate pediatric critical care procedures, and to document the safety profile of ketamine in this setting. Design Retrospective consecutive case series. Setting Pediatric intensive care unit of a tertiary children’s hospital. Patients Children receiving ketamine for procedural sedation over a 5-year period. Interventions We reviewed patient records to determine indication, dosing, adverse events, inadequate sedation, and recovery time for each sedation. Outcome Measures Descriptive features of sedation including adverse events. Results During the study period, children in our pediatric intensive care unit received ketamine at total of 442 times to facilitate a wide variety of critical care procedures, most commonly central line placement, esophagogastroduodenoscopy, and wound debridement. Most study children had substantial underlying illness (ASA ≥ 3 in 88%; ASA ≥ 4 in 39%). Inadequate sedation was noted in only nine (2%) procedures. Adverse effects included transient laryngospasm (n = 9), transient partial airway obstruction (n = 5), apnea with bradycardia (n = 1), emesis during the procedure (n = 2), emesis during recovery (n = 9), mild recovery agitation (n = 10), moderate-to-severe recovery agitation (n = 1), and excessive salivation (n = 4). There were no adverse outcomes attributable to ketamine. Conclusion Pediatric intensivists skilled in ketamine administration can safely and effectively administer this drug to facilitate critical care procedures. Despite the ill nature of our patient sample, adverse effects were uncommon.

Simulation in Medical School Education: Review for Emergency Medicine

Medical education is rapidly evolving. With the paradigm shift to small-group didactic sessions and focus on clinically oriented case-based scenarios, simulation training has provided educators a novel way to deliver medical education in the 21st century. The field continues to expand in scope and practice and is being incorporated into medical school clerkship education, and specifically in emergency medicine (EM). The use of medical simulation in graduate medical education is well documented. Our aim in this article is to perform a retrospective review of the current literature, studying simulation use in EM medical student clerkships. Studies have demonstrated the effectiveness of simulation in teaching basic science, clinical knowledge, procedural skills, teamwork, and communication skills. As simulation becomes increasingly prevalent in medical school curricula, more studies are needed to assess whether simulation training improves patient-related outcomes.

An educational course including medical simulation for early goal-directed therapy and the severe sepsis resuscitation bundle: An evaluation for medical student training ,

OBJECTIVE Widespread application of early goal-directed therapy (EGDT) and the severe sepsis resuscitation bundle is limited by clinician knowledge, skills and experience. This study evaluated use of simulation-based teaching during medical training to increase future clinician knowledge in the above therapies for severe sepsis and septic shock. METHODS A prospective cohort study was performed with medical students at all levels of training. A 5-h course including didactic lectures, skill workshops, and a simulated case scenario of septic shock were administered to the participants. A checklist including 21 tasks was completed during the patient simulation. An 18-question pre-test, post-test and 2-week post-test were given. The participants completed a survey at the end of the course. RESULTS Sixty-three students were enrolled. There was statistical difference between the pre-test and each of the post-test scores: 57.5+/-13.0, 85.6+/-8.8, and 80.9+/-10.9%, respectively. 20.6% of participants thought the pre-test was too difficult, whereas all participants thought the post-test was either appropriate or too easy. The task performance during the simulated septic shock patient was 94.1+/-6.0%. The participants noted improvements in their confidence levels at managing severe sepsis and septic shock, and agreed that the course should be a requirement during medical school training. CONCLUSIONS Medical simulation is an effective method of educating EGDT and the severe sepsis resuscitation bundle to medical students with limited experience in patient care. The results suggest that our course may be of further benefit at increasing clinical experience with this intensive protocol for the management of severe sepsis and septic shock.

Blunt pediatric head trauma requiring neurosurgical intervention: how subtle can it be?

Recent literature on pediatric head injuries has suggested that important intracranial injuries might present to the ED without typical signs or symptoms. The objective of our study was to review our institutional experience with head-injured infants and young children to assess the subtlety of the ED presentation. We performed a retrospective medical record review of head-injured children </=10 years of age who underwent neurosurgical procedures from January 1, 1985, through November 28, 2001. We identified 110 children who met our inclusion criteria. All of the children had at least 2 signs or symptoms indicative of head injury. No single sign or symptom was present in all cases. Altered mental status was identified 85% of the time and was the most common sign or symptom. Eighteen children presented with a Glasgow Coma Scale score of 15 or the absence of abnormal mental status documented, but all of these children had other indications for head computed tomographic scanning. Emergency physicians should feel confident that standard history and physical examination skills are adequate to identify head-injured children who require neurosurgical procedures.

Investigation of afebrile neonates with a history of fever.

OBJECTIVE Our objective was to describe clinically significant infections in a cohort of afebrile neonates who underwent an emergency department (ED) septic workup because of the history of a measured fever at home. METHODS Retrospective medical record review of all infants (3/4)28 days of age who presented to our tertiary care pediatric ED between Jan. 1, 1999, and Aug. 22, 2002, underwent lumbar puncture in the ED, had a reported temperature at home of >or=38 degrees C, and an ED triage temperature of <38 degrees C. Laboratory and radiographic results were tabulated. RESULTS During the study period, 206 neonates underwent lumbar puncture in our ED. Of these, 108 were excluded because their home temperature was not documented, and 71 were excluded because they were still febrile on presentation to the ED. The study group consisted of the remaining 27 subjects, 4 of whom had received acetaminophen prior to ED arrival. Infections were confirmed in 10 (37%) subjects (3 urinary tract infections, 2 aseptic meningitis, 1 enterovirus meningitis, 1 respiratory syncytial virus bronchiolitis, 1 rotavirus enteritis and 2 pneumonias). CONCLUSIONS Clinically important infections are not uncommon among afebrile neonates undergoing ED septic workup because of a measured fever at home. Some diagnostic testing is warranted in this group, although the clinical utility and indications for specific test modalities remain unclear.

The Role of Morphine in a Rat Model of Hypoxic-ischemic Injury

We investigated whether morphine plays a neuroprotective role in a neonatal rat pup model of bilateral carotid artery occlusion with hypoxia. At postnatal day 10, rats received either morphine (n = 7), naloxone (n = 7), or saline placebo (n = 15) after hypoxic-ischemic injury. Survival (days), weight gain and animal testing (negative geotaxis, surface righting, and rotarod) were compared between treatment groups. Lesion volume was delineated with magnetic resonance imaging at days 7 and 28-57 after injury. Survival in rats treated with morphine, naloxone, or saline was, respectively, 14, 29, and 73%. Median number of days of survival after bilateral carotid artery occlusion with hypoxia treated with morphine was 4 (95% confidence interval 4 to 22), with naloxone was 3 (95% confidence interval -1.4 to 21), and with placebo was 28 (95% confidence interval 18 to 28). There were no statistically significant differences in magnetic resonance imaging-derived ischemic lesion volumes, weight gain, or behavioral testing measures between the groups. Morphine was ineffective as a neuroprotectant in rat pups with severe hypoxic-ischemic injury and may have contributed to their decreased survival.

Intramuscular ketamine to facilitate pediatric central vascular access.

OBJECTIVES Obtaining prompt vascular access in young children presenting to the emergency department (ED) is frequently both necessary and technically challenging. The objective of our study was to describe our experience using intramuscular (IM) ketamine to facilitate the placement of central venous catheters in children presenting to our ED needing vascular access in a timely fashion. METHODS We performed a retrospective medical record review of all pediatric patients <18 years of age who presented to our tertiary care pediatric ED between May 1, 1998, and August 7, 2003, and underwent the placement of a central venous catheter facilitated by the use of IM ketamine. RESULTS Eleven children met our inclusion criteria. Most of the children were young and medically complicated. The children ranged in age from 6 months to 8 years. The only complication identified was vomiting experienced by an 8-year-old boy. Emergency physicians successfully obtained central venous access in all subjects in the case series. CONCLUSIONS The use of IM ketamine to facilitate the placement of central venous catheters in children who do not have peripheral venous access appears to be helpful. Emergency physicians may find it useful to be familiar with this use of IM ketamine.

The removal of coins from the upper esophageal tract of children by emergency physicians: a pilot study

OBJECTIVE There are few reports in the medical literature describing removal of a coin from the upper esophageal tract of a child by an emergency physician. However, given the nature of their training and practice, emergency physicians are well suited to perform this common procedure. We describe our experience with this procedure. METHODS This was a retrospective review of a continuous quality improvement data set from a university-based tertiary care pediatric emergency department between Nov. 1, 2003, and Mar. 31, 2004. RESULTS Thirteen children, with a median age of 20 months, underwent rapid sequence intubation and had coins successfully removed from their upper esophageal tract by emergency physicians. In 10 cases, the coin was visible at laryngoscopy and removed with Magill forceps. In 3 cases this approach failed and a Foley catheter was used to remove the coin. One child suffered a tonsillar abrasion and two sustained minor lip trauma, but all were extubated and discharged home from the emergency department with no significant complications. Eleven of the 13 patients were successfully followed up, and the parents reported no problems. CONCLUSIONS This pilot study suggests that the removal of a coin from the upper esophageal tract by an emergency physician can be both safe and effective. A larger study is needed before this procedure can be generally recommended.

Pediatric emergency department census during major sporting events

Objectives Our study attempted to evaluate the effects of major sporting events on the census of a pediatric emergency department (ED) in the United States specifically related to the National Football League Super Bowl, National Basketball Association (NBA) Finals, and Major League Baseball World Series. Methods We performed a retrospective data analysis of our pediatric ED census on the number of visits during major sporting events over a 5-year period. Data during the same period 1 week after the major sporting event were collected for comparison as the control. We evaluated the medians of 2-hour increments around the event start time. Subgroup analysis was performed for games involving the local sporting teams. Results Our results showed no significant difference in ED census during the sporting events, except in the post 6 to 8 hours of the NBA finals. Subgroup analysis of the Los Angeles Lakers showed the same significant findings in the post 6 to 8 hours of the NBA finals. Conclusions No major difference in pediatric ED census is observed during the most major sporting events in the United States.

Intraabdominal Abscess Masquerading as a Properly Replaced Gastrostomy Tube

Percutaneous endoscopic gastrostomy (PEG) tubes have been used as a means of supporting nutrition in children since 1980. Since 1984, gastrostomy “button” tubes have been available and have gained popularity for their cosmetic appeal and greater acceptance by parents and families.1 Emergency physicians need to be comfortable with replacement of malfunctioned gastrostomy tubes. The perils of gastrostomy tube replacement are well documented,1-3 and with difficult replacements, it is recommended to check gastrostomy tube placement with different techniques including a contrast-enhanced study.4 To our knowledge, this is the first case report of an error in interpretation of the contrast study due to an abscess formation. Case