Ketamine for Prehospital Pain Management Does Not Prolong Emergency Department Length of Stay.

BACKGROUND: Ketamine is gaining acceptance as an agent for prehospital pain control, but the associated risks of agitation, hallucinations and sedation have raised concern about its potential to prolong emergency department (ED) length of stay (LOS). This study compared ED LOS among EMS patients who received prehospital ketamine, fentanyl or morphine specifically for pain control. We hypothesized ED LOS would not differ between patients receiving the three medications. METHODS: This retrospective observational study utilized the 2018 ESO Research Database, which includes more than 7.5 million EMS events attended by more than 1,200 agencies. Inclusion criteria were a 9-1-1 scene response; age ≥ 18 years; a recorded pain score greater than 4; an initial complaint or use of a treatment protocol indicating a painful condition; prehospital administration of ketamine, fentanyl or morphine; and ED LOS data available. Patients were excluded if they received a combination of the medications, or if there were indications that medication administration could have been for airway management (i.e., altered mental status, head injury, respiratory distress/depression) or agitation control (e.g., behavioral complaints). Kruskal-Wallis test was used to compare ED LOS among patients receiving each of the three medications. Post-hoc evaluations of between-group differences were conducted using Wilcoxon Rank Sum test and a Bonferroni-corrected alpha value of 0.017. RESULTS: Of 9,548 patients who met the inclusion criteria, 119 received ketamine, 1,359 received morphine, and 8,070 received fentanyl. Patient and event characteristics did not significantly differ between the three groups. Median (IQR) ED LOS was 3.5 (2.5-6.1) hours for patients who received ketamine, 4.0 (2.7-6.1) hours for patients who received morphine, and 3.7 (2.6-5.4) hours for patients who received fentanyl (p = 0.002). In post-hoc pairwise comparisons, patients who received morphine had significantly longer ED LOS than patients who received fentanyl (p < 0.001); there was no significant difference in ED LOS for patients who received ketamine vs. morphine (p = 0.161) or for patients who received ketamine vs. fentanyl (p = 0.809). CONCLUSION: ED LOS is not longer for patients who receive prehospital ketamine, versus morphine or fentanyl, for management of isolated painful non-cardiorespiratory conditions.

Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data.

STUDY OBJECTIVE: We compare reported crash rates for US ambulances responding to or transporting patients from a 911 emergency scene with or without lights and sirens. Our null hypothesis is that there will be no difference in the rate of ambulance crashes whether lights and sirens are used. METHODS: For this retrospective cohort study, we used the 2016 National EMS Information System data set to identify 911 scene responses and subsequent patient transports by transport-capable emergency medical services (EMS) units. We used the system's "response mode to scene" and "transport mode from scene" fields to determine lights and sirens use. We used the "type of response delay" and "type of transport delay" fields to identify responses and transports that were delayed because of a crash involving the ambulance. We calculated the rate of crash-related delays per 100,000 responses or transports and used multivariable logistic regression with clustered (by agency) standard errors to calculate adjusted odds ratios (AORs) (with 95% confidence intervals [CIs]) for the association between crash-related delays and lights and sirens use for responses and transports separately. RESULTS: Among 19 million included 911 scene responses, the response phase crash rate was 4.6 of 100,000 without lights and sirens and 5.4 of 100,000 with lights and sirens (AOR 1.5; 95% CI 1.2 to 1.9). For the transport phase, the crash rate was 7.0 of 100,000 without lights and sirens and 17.1 of 100,000 with lights and sirens (AOR 2.9; 95% CI 2.2 to 3.9). Excluding responses and transports with only partial lights and sirens use did not meaningfully alter the results (response AOR 1.5, 95% CI 1.2 to 1.9; transport AOR 2.8, 95% CI 2.1 to 3.8). CONCLUSION: Ambulance use of lights and sirens is associated with increased risk of ambulance crashes. The association is greatest during the transport phase. EMS providers should weigh these risks against any potential time savings associated with lights and sirens use.

Adverse events following emergent prehospital sedation of patients with behavioral emergencies: A retrospective cohort study.

Background: Patients presenting to emergency medical services (EMS) with behavioral emergencies may require emergent sedation to facilitate care, but concerns about sedation-related adverse events (AEs) exist. This study aimed to describe the frequency of AEs following emergent prehospital sedation with three types of sedative agents: ketamine, benzodiazepines and antipsychotics. Methods: This retrospective cohort study included patients ≥ 15 years who presented to 1031U.S. EMS agencies in calendar year 2019 with behavioral emergencies necessitating emergent prehospital sedation. Serious AEs (SAE) included cardiac arrest, invasive airway placement, and severe oxygen desaturation (<75%). Less-serious AEs included positive pressure ventilation, any oxygen desaturation (<90%), oropharyngeal or nasopharyngeal airway placement, and suctioning. The need for additional sedation was also assessed. Findings: Of 7973 patients, 1996 received ketamine; 4137 received a benzodiazepine; 1532 received an antipsychotic agent; and 308 received an indeterminant agent. Cardiac arrest occurred in 11 patients (0·1%) and any SAE occurred in 165 patients (2·1%). Invasive airway placement was more frequent with ketamine (40, 2·0%) compared with benzodiazepines (17, 0·4%) or antipsychotics (3, 0·2%). Oxygen desaturation below 75% also occurred more frequently with ketamine (51, 2·6%) than with benzodiazepines (52, 1·3%) or antipsychotics (14, 0·9%). Patients sedated with ketamine were less likely to require additional sedation. Propensity-matching to minimize potential confounding between patient condition, sedative choice and AEs did not meaningfully alter the results. Interpretation: Although SAEs were rare among patients receiving emergent prehospital sedation, prehospital clinicians should remain mindful of the potential risks and monitor patients closely. Funding: None.