Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department.

BACKGROUND: The co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. OBJECTIVE: Our objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED). METHODS: This was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21 years of age. The attending physician administered either ketamine 1 mg/kg i.v. or ketamine 0.5 mg/kg and propofol 0.5 mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5 mg/kg/dose) or ketamine/propofol (0.25 mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores. RESULTS: Ninety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores by providers, including nurses, were higher for KM, although parents were equally satisfied with both sedation regimens. CONCLUSIONS: We found no significant differences in adverse events between the KM and CoKP groups. While CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

The 2012 PEMpix photograph competition award winner: making a case for pringles-flavored carrots.

This is a case report of a 14-year-old boy with autism who presented with photophobia. Physical examination was significant for bilateral corneal ulcers. Differential diagnosis of this chief complaint and the management of the suspected condition are discussed. This case was presented at the Section of Emergency Medicine Meeting at the National Conference and Exhibition of the American Academy of Pediatrics in 2012 and was awarded first place in the PEMpix photograph competition.

Transformation of late passage insulin-like growth factor-I receptor null mouse embryo fibroblasts by SV40 T antigen.

There is evidence that the insulin-like growth factor-I (IGF-I) receptor is required for transformation by a variety of viral and cellular oncogenes in a mouse embryo fibroblast model. To further investigate the IGF-I receptor signaling pathways that are required for the permissive effect of the receptor on transformation by SV40 T antigen, we established three independent fibroblast cell lines each from wild-type and IGF-I receptor null embryos (R-). We transfected the wild-type and R- cell lines with an SV40 T antigen plasmid and selected three clones from each cell line that expressed T antigen. As in previous reports, none of the cloned R- cell lines expressing T antigen were transformed as measured by the ability to form large colonies in soft agar. However, with further passage, all three T antigen-expressing clones from one of the R- cell lines (R(-)3) formed large colonies in soft agar and the transformation of these T antigen-expressing clones was confirmed by tumorigenesis experiments in immunodeficient mice. DNA microarray analysis comparing gene expression between early passage and late passage R(-)3/T antigen clones showed, among other changes, an increase in the expression of ErbB-3 mRNA in the late passage clones. Also, the expression of ErbB-3 protein was dramatically increased in the late passage R(-)3/T antigen clones. We conclude that late passage IGF-I receptor null mouse embryo fibroblasts can be transformed by SV40 T antigen, and that ErbB-3 may play a role in permitting transformation by T antigen.

Emergency management of pediatric skin and soft tissue infections in the community-associated methicillin-resistant Staphylococcus aureus era.

OBJECTIVES: Skin and soft tissue infections (SSTIs) are increasing in incidence, yet there is no consensus regarding management of these infections in the era of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). This study sought to describe current pediatric emergency physician (PEP) management of commonly presenting skin infections. METHODS: This was a cross-sectional survey of subscribers to the American Academy of Pediatrics Section on Emergency Medicine (AAP SoEM) list-serv. Enrollment occurred via the list-serv over a 3-month period. Vignettes of equivocal SSTI, cellulitis, and skin abscess were presented to participants, and knowledge, diagnostic, and therapeutic approaches were assessed. RESULTS: In total, 366 of 606 (60.3%) list-serv members responded. The mean (+/- standard deviation [SD]) duration of practice was 13.6 (+/-7.9) years, and 88.6% practiced in a pediatric emergency department. Most respondents (72.7%) preferred clinical diagnosis alone for equivocal SSTI, as opposed to invasive or imaging modalities. For outpatient cellulitis, PEPs selected clindamycin (30.6%), trimethoprim-sulfa (27.0%), and first-generation cephalosporins (22.7%); methicillin-sensitive S. aureus (MSSA) was routinely covered, but many regimens failed to cover CA-MRSA (32.5%) or group A streptococcus (27.0%). For skin abscesses, spontaneous discharge (67.5%) was rated the most important factor in electing to perform a drainage procedure; fever (19.9%) and patient age (13.1%) were the lowest. PEPs elected to prescribe trimethoprim-sulfamethoxazole (TMP-Sx; 50.0%) or clindamycin (32.7%) after drainage; only 5% selected CA-MRSA-inactive agents. All PEPs suspected CA-MRSA as the etiology of skin abscesses, and many attributed sepsis (22.1%) and invasive pneumonia (20.5%) to CA-MRSA, as opposed to MSSA. However, 23.9% remained unaware of local CA-MRSA prevalence for even common infections. CONCLUSIONS: Practice variation exists among PEPs for management of SSTI. These results can be used to measure changes in SSTI practices as standardized approaches are delineated.