Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine for Treating Acute Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind, Double-Dummy Controlled Trial.

STUDY OBJECTIVE: We aimed to assess and compare the analgesic efficacy and adverse effects of intravenous subdissociative-dose ketamine to nebulized ketamine in emergency department (ED) patients with acute painful conditions. METHODS: We conducted a prospective, randomized, double-blind, double-dummy clinical trial in adult patients (ages 18 and older) with a numerical rating scale pain score of ≥5. We randomized subjects to receive either a single dose of 0.3 mg/kg of intravenous (IV) ketamine or 0.75 mg/kg of nebulized ketamine through a breath-actuated nebulizer. Primary outcome was the difference in pain scores on the numerical rating scale between groups at 30 minutes postmedication administration. The secondary outcomes included the need for rescue analgesia, occurrences of adverse events in each group, and the difference in pain scores at 15, 30, 60, 90, and 120 minutes. We calculated a 95% confidence interval (CI) for a mean difference at 30 minutes, with a minimum clinically important difference set at 1.3 points. RESULTS: We enrolled 150 subjects (75 per group). Mean pain scores through numerical rating scale were 8.2 for both groups at baseline, which decreased to 3.6 and 3.8 at 30 minutes, yielding a mean difference of 0.23 (95% CI -1.32 to 0.857). We observed no clinically concerning changes in vital signs. No serious adverse events occurred in any of the groups throughout the study period. CONCLUSION: We found no difference between the administration of IV and nebulized ketamine for the short-term treatment of moderate to severe acute pain in the ED, with both treatments providing a clinically meaningful reduction in pain scores at 30 minutes.

Perceptions and Barriers to Administering Vasopressors in the Prehospital Setting.

Introduction Vasopressor administration is a critical medical intervention for patients with hypotension in undifferentiated shock states. Over the years, prehospital care has advanced with protocols and training that allow paramedics in the field to administer a variety of vasopressors. The primary objective of this investigation was to evaluate vasopressor experience among paramedics with regard to preference as well as the barriers to its preparation and administration. Methods A cross-sectional survey of vasopressor use by nationally certified paramedics (NRPs) was performed. A 20-item questionnaire was constructed to capture the prehospital perceptions and barriers of dopamine infusion, norepinephrine infusion, and IV bolus "push-dose" epinephrine (PD-E). Data collection was carried out from June to September 2021. Results A total of 44 responses were obtained (response rate = 44%). All participants had experience using vasopressors and understood their medical indications. Overall, PD-E was the most common vasopressor used in the prehospital setting, and participants felt equally confident in "using" and "preparing" it. Participants felt less confident with "using" and "preparing" vasopressors that required channel setup and maintaining a flow rate. Younger paramedics with less than five years of experience were more eager to use norepinephrine if trucks were stocked with pre-mixed norepinephrine rather than the current formulation that required compounding.  Conclusion This study provided preliminary data that evaluated perceptions of vasopressor use in the prehospital setting among paramedics in a large urban environment. Preference and barriers to its preparation and administration were surveyed. Further research is needed to identify the interventions to reduce barriers and allow paramedics to be less limited by logistical considerations when choosing vasopressors in the prehospital setting.

Implementation of a novel digital ultrasound education tool into an emergency medicine rotation: UltrasoundBox.

Objective: We investigated the educational value of implementing a web-based e-learning program into a medical student emergency medicine rotation. We created "UltrasoundBox," a browser-based application where students interpret ultrasound (US) images. Our goal was to assess how this form of e-learning performs when compared to more passive, lecture-based online US education. We also assessed the how the students interpreted the addition this learning modality to the rotation. Methods: This is a randomized, controlled study to assess the educational outcomes of implementing UltrasoundBox compared to lecture-based US education. Fourth-year medical students on their emergency medicine rotation were enrolled in the study. Students randomized to the control arm were instructed to watch widely available educational lecture videos. Students randomized to the intervention arm received access to UltrasoundBox and were instructed to complete the clinical modules. Both groups completed the same standardized US examination before and after the trial. All the trial participants were given a survey to complete after the trial. Results: We enrolled 42 students, with 23 in the control group and 19 in the intervention group. On the post-intervention examination, the control and intervention groups were found to have mean examination scores of 61.6% and 73.6% respectively, with a statistically significant difference of 12% (95% confidence interval 1.611 to 5.56; p < 0.0005). A total of 92% of survey respondents in the intervention group indicated that UltrasoundBox was an effective tool in meeting the intended learning objectives, while only 36.8% of the control group indicated this for the online lectures (p < 0.005). Conclusions: We found that medical students using the web-based e-learning platform UltrasoundBox achieved better scores on the examination when compared to the medical students using existing online lecture-based US educational resources. The students reported that the addition of UltrasoundBox added educational value to the rotation.

Oral Aspirin/ketamine versus oral ketamine for emergency department patients with acute musculoskeletal pain.

OBJECTIVE: The purpose of this study is to investigate if an orally administered combination of aspirin and ketamine will provide better analgesia than a ketamine alone in adult patients presenting to the Emergency Department (ED) with acute musculoskeletal pain. METHODS: We conducted a prospective, randomized, open-label trial of ED patients aged 18 and older presenting with moderate to severe acute musculoskeletal pain as defined by an 11-point numeric rating scale (NRS) with an initial score of ≥5. Patients were randomized to receive either 324 mg of VTS-Aspirin™ and 0.5 mg/kg of oral ketamine (AOK) that is directly swallowed or 0.5 mg/kg of oral ketamine (OK) alone that is swished first and then swallowed. Patients were assessed at baseline, 30, 60, 90, and 120 min. The primary outcome was a difference in pain scores between the two groups at 60 min post-administration. Secondary outcomes included adverse events and the need for rescue analgesia. RESULTS: We enrolled 60 patients in the study (30 per group). The difference in mean pain scores at 60 min between the AOK and OK groups was 2.6 [95% CI: 1.38-3.77] showing a lower mean pain score in the OK group. At 60 min, the AOK group had a change in mean pain score from 8.4 to 6.3 (difference 2.1; 95% CI: 1.35-3.00). The OK group had a change in mean pain score from 7.8 to 3.7 (difference 4.1, 95% CI: 3.25-4.90). No clinically concerning changes in vital signs were observed. No serious adverse events occurred in either group. The most commonly reported adverse effects were dizziness and fatigue. None of the participants required rescue analgesia at 60 min post-medications administration. CONCLUSION: The administration of an oral combination of VTS-Aspirin ™ and ketamine resulted in less analgesia compared to oral ketamine alone, for the short-term treatment of moderate to severe acute musculoskeletal pain in the ED. CLINICALTRIALS: govRegistration: NCT04860804.

Analgesic Efficacy of Oral Aspirin/Ketamine Combination for Management of Acute Musculoskeletal Pain in the Emergency Department - A Proof of Concept Pilot Study.

BACKGROUND: Musculoskeletal pain (MSK) affects one out of three adults and is the most common source of significant long-term pain, physical disability, and under-treatment in the emergency department (ED). OBJECTIVE: We aimed to assess the analgesic efficacy of a combination of oral VTS-Aspirin® (Vitalis Analgesics, New York, NY) and ketamine in managing acute MSK pain in adult ED patients. METHODS: This was a prospective, proof-of-concept, single-arm, pilot study evaluating the analgesic efficacy of a single dose of oral combination of VTS-Aspirin and ketamine in adult ED patients with acute moderate-to-severe MSK pain. The primary outcome included the difference in pain scores on an 11-point numeric pain rating scale at 60 min. Secondary outcomes included the need for rescue analgesia, the occurrence of adverse events at 60 min, and a change in pain scores at 120 min. RESULTS: We enrolled 25 subjects in the study. The mean baseline pain score was 8.6 and the mean pain score at 60 min decreased to 4.8. The oral ketamine dose ranged from 24 mg to 50 mg, with a mean dose of 37.8 mg. No clinically concerning changes in vital signs were noted. No serious adverse events occurred in any of the subjects. Majority of adverse effects were transient and weak in intensity. CONCLUSION: We demonstrated that administration of an oral combination of VTS-Aspirin and ketamine to adult ED patients with acute MSK pain resulted in clinically significant pain relief in 80% of enrolled subjects.

Take-Pause: Efficacy of mindfulness-based virtual reality as an intervention in the pediatric emergency department.

BACKGROUND: Emergency department (ED) visits are known to be anxiety-ridden and stress-provoking experiences especially in the pediatric population. Distraction techniques have been used as a means to reduce anxiety and stress thereby facilitating care in the ED and making the visit less unpleasant. Our study aimed to evaluate the effectiveness of an active and immersive distraction technique, using a mindfulness-based virtual reality (VR) program (Take-Pause), to alleviate anxiety in pediatric ED patients. METHODS: A prospective, randomized, single-blinded study, evaluating ED patients aged 13-17 years with a chief complaint of acute pain was conducted. Patients were randomized either to the active distraction intervention (VR group), utilizing the VR headset for 5 min, or to the passive distraction intervention (iPad group), playing on an iPad for 5 min. The primary outcome was a difference in the change in anxiety scores on the Spielberger State-Trait Anxiety Inventory between the two groups. Secondary outcomes included a difference in pain scores, respiratory rate, and heart rate between the groups. RESULTS: A total of 110 subjects were enrolled. At 15 min, the mean anxiety score for the VR group improved by 10 points versus 6 points in the iPad group (p < 0.001; 95% confidence interval = 0.44 to 7.6). There was no statistical significance in the reduction of pain scores (p = 0.953) and respiratory rates (p = 0.776) between the groups. Patients enrolled in both groups did not experience any adverse effects. CONCLUSION: Take-Pause, offering an active and immersive distraction technique, is more effective than a passive distraction approach to lower anxiety levels in adolescent ED patients.

Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial.

STUDY OBJECTIVE: We aimed to assess and compare the analgesic efficacies and adverse effects of ketamine administered through a breath-actuated nebulizer at 3 different dosing regimens for emergency department patients presenting with acute and chronic painful conditions. METHODS: This was a prospective, randomized, double-blinded trial comparing 3 doses of nebulized ketamine (0.75 mg/kg, 1 mg/kg, and 1.5 mg/kg) administered through breath-actuated nebulizer in adult emergency department patients aged 18 years and older with moderate to severe acute and chronic pain. The primary outcome included the difference in pain scores on an 11-point numeric rating scale between all 3 groups at 30 minutes. Secondary outcomes included the need for rescue analgesia (additional doses of nebulized ketamine or intravenous morphine) and adverse events in each group at 30 and 60 minutes. RESULTS: We enrolled 120 subjects (40 per group). The difference in mean pain scores at 30 minutes between the 0.75 mg/kg and 1 mg/kg groups was 0.25 (95% confidence interval [CI] 1.28 to 1.78); between the 1 mg/kg and 1.5 mg/kg groups was -0.225 (95% CI -1.76 to 1.31); and between the 0.75 mg/kg and 1.5 mg/kg groups was 0.025 (95% CI -1.51 to 1.56). No clinically concerning changes in vital signs occurred. No serious adverse events occurred in any of the groups. CONCLUSION: We found no difference between all 3 doses of ketamine administered through breath-actuated nebulizer for short-term treatment of moderate to severe pain in the emergency department.

Language Barriers and Timely Analgesia for Long Bone Fractures in a Pediatric Emergency Department.

INTRODUCTION: Long bone fractures are common painful conditions often managed in the pediatric emergency department (PED). Delay to providing effective pediatric pain management is multifactorial. There is limited information regarding how the issue of language spoken impacts the provision of adequate and timely institution of analgesia. We sought to determine whether there is a difference between English-speaking and non-English speaking patients with respect to time to pain management for long bone fractures in a multi-ethnic urban PED. METHODS: We conducted a retrospective cohort study of consecutive cases over 29 months of children <18 years old who presented to the PED with a first-time long bone fracture. A correlation of multiple clinical variables with timeliness to providing analgesia as a primary outcome was determined. We performed regression analysis to eliminate confounding and to determine the magnitude of each variable's effect on the outcome. RESULTS: We analyzed a total of 753 patient cases (power 0.95). Regression analysis showed that the variable of English vs non-English language spoken was the most significant predictor of timeliness to pain management (p < 0.001). There was a significant difference in median time to triage measurement of pain score (1 minute vs 4 minutes for English vs non-English speakers [p < 0.001]); median time to initial analgesia (4 minutes vs 13 minutes for English vs non-English speakers (p < 0.001]); and median time to opioid analgesia (32 minutes vs 115 minutes for English vs non-English speakers (p < 0.001]), respectively. All measurements of time were from the creation of a patient's electronic health record. Just 30% of all patients received an opioid analgesic for treatment of long bone fractures, including only 37% with moderate triage pain scores. CONCLUSION: Delay to receiving analgesic medications in pediatric patients with long bone fractures can be augmented by language barriers. Time to providing analgesia for long bone fractures is significantly delayed in non-English speaking families, contributing to disproportionate care in the PED. Furthermore, use of opioid analgesia for fractures in children remains poor.

Diagnostic Accuracy of Point-Of-Care Ultrasound for Intussusception Performed by Pediatric Emergency Medicine Physicians.

BACKGROUND: Intussusception (INT) is a common cause of bowel obstruction in young children. Delay in diagnosis can lead to significant morbidity and mortality. There have been several studies evaluating early point-of-care ultrasound (POCUS) in the diagnosis of INT by nonradiologists. OBJECTIVE: Our objective was to determine the diagnostic accuracy of POCUS by novice sonographer pediatric emergency medicine physicians (PEM-Ps) who received focused US training for diagnosing INT. METHODS: We performed a prospective observational study including 17 PEM-Ps (14 attendings, 3 fellows) trained to perform abdominal US for INT. Children suspected of having INT received POCUS performed and interpreted by a PEM-P, followed by a US study performed by a certified ultrasonographer and interpreted by an attending pediatric radiologist. Diagnostic concordance between PEM-P-and radiology-performed US (RPUS) results was assessed. RESULTS: One hundred patients were enrolled; median patient age was 24 months. There was excellent diagnostic agreement for presence or absence of INT between PEM-Ps and RPUS (97% of cases; κ = 0.826). POCUS-diagnosed INT was present in 8 of 9 patients with RPUS-diagnosed INT (sensitivity 89%; 95% confidence interval [CI] 51-99%; specificity 98%; 95% CI 92-100%; positive predictive value 80%; 95% CI 44-96%; negative predictive value 99%; 95% CI 93-100%). Likelihood ratio for INT with a positive POCUS was 40.44 (95% CI 10.07-162.36) and with a negative POCUS was 0.11 (95% CI 0.02-0.72). CONCLUSIONS: POCUS performed by novice sonographers to diagnose INT has high diagnostic concordance with RPUS. Emergency department-performed POCUS is a rapid and accurate method for diagnosing INT.

Analgesic efficacy of morphine sulfate immediate release vs. oxycodone/acetaminophen for acute pain in the emergency department.

OBJECTIVE: Previous research demonstrated that administration of Morphine Sulfate Immediate Release (MSIR) results in similar analgesic efficacy to Oxycodone but with significantly lesser degrees of euphoria and reward. The purpose of this study sit to investigate if MSIR combined with Acetaminophen can serve as an opioid analgesic alternative to Oxycodone combined with acetaminophen (Percocet) for acute pain in the Emergency Department (ED). METHODS: A prospective, randomized, double-blind trial of ED patients aged 18 to 64 years presenting with moderate to severe acute pain as defined by an 11-point numeric rating scale (NRS) with an initial score of ≥5 (0 = no pain and 10 = very severe pain). Patients were randomized to receive either 15 mg MSIR combined with 650 mg of Acetaminophen or 10 mg Oxycodone combined with 650 mg Acetaminophen. Patients were assessed at baseline, 30, 45 and 60 min. The primary outcome was reduction in pain at 60 min. Secondary outcomes include drug likeability and adverse events. RESULTS: 80 patients were enrolled in the study (40 per group). Demographic characteristics were similar between the groups (P > 0.05). Mean NRS pain scores at baseline were 8.44 for the MSIR group and 8.53 for the Percocet group (P = 0.788). Mean pain scores decreased over time but remained similar between the groups: 30 min (6.03 vs. 6.43; P = 0.453), 45 min (5.31 vs. 5.48; P = 0.779), and 60 min (4.22 vs. 4.87; P = 0.346). Reduction in mean NRS pain scores were statistically significant from baseline to 30, 45 and 60 min within each group (P < 0.0001 at each time point for both groups). The largest NRS mean difference was from baseline to 60 min: 4.2 (95% CI: 3.43 to 5.01) for MSIR group and 3.61 (95% CI: 2.79 to 4.43) for Percocet group. No clinically significant changes or any serious adverse events were observed in either group. CONCLUSION: MSIR provides similar analgesic efficacy as Percocet for short-term pain relief in the ED, similar rates of nausea/vomiting, and lower rates of likeability of the drug.

Analgesic Efficacy of Intranasal Ketamine Versus Intranasal Fentanyl for Moderate to Severe Pain in Children: A Prospective, Randomized, Double-Blind Study.

PURPOSE: This study aimed to compare analgesic efficacy of intranasal (IN) ketamine to IN fentanyl for moderate to severe pain in children in a pediatric emergency department. METHODS: A prospective, randomized, double-blinded, noninferiority study evaluating children aged 3 to 17 years in a pediatric emergency department with acute moderate to severe pain was conducted. Patients received either 1 mg/kg of IN ketamine or 1.5 µg/kg of IN fentanyl and were evaluated after 10, 20, 30, and 60 minutes. The primary outcome was the degree of pain reduction after 20 minutes. RESULTS: Twenty-two patients were enrolled (11 in each group). Underlying pain conditions represented were musculoskeletal injury (73%) and abdominal pain (27%). At 20 minutes after analgesia, there was no significant difference in pain scores between the fentanyl (median, 2; range, 0-8) and ketamine groups (median, 4; range, 0-7; P = 0.20). The ketamine group showed a significantly greater rate of adverse effects, 73% versus 9% (P = 0.002), and throughout the course of the study period, 7 patients in the ketamine group (64%) group showed some degree of sedation versus no one in the fentanyl group (P = 0.004). CONCLUSIONS: There was insufficient power to support the analgesic noninferiority of IN ketamine at a dose of 1 mg/kg compared with IN fentanyl at a dose of 1.5 µg/kg in children experiencing painful conditions at 20 minutes after administration. Intranasal ketamine was found to be inferior to IN fentanyl in relieving pain at 10 minutes and was found to have significantly greater rates of sedation and dizziness.

Description of Adverse Events in a Cohort of Dance Festival Attendees with Stimulant-Induced Severe Agitation Treated with Dissociative-Dose Ketamine.

BACKGROUND: Emergency clinicians often treat severe agitation resulting from intoxicants, psychiatric illness, and other CNS or systemic diseases. Recreational drugs-especially stimulants-are frequently used by attendees of electronic dance music festivals (EDMFs), and festivalgoers may become dangerously agitated and pose an immediate threat to themselves and others. Although benzodiazepines and antipsychotics are classically used to treat severe agitation, these medications are burdened by safety concerns including respiratory depression and cardiac arrhythmias. The effects of ketamine when used to treat severe agitation in an exclusive cohort of patients with psychostimulant drug-induced toxicity (PDIT) has not previously been reported, and existing literature describes a widely variant safety profile when ketamine is used for sedation of the agitated patient. OBJECTIVE: To describe ketamine's adverse event profile when used to treat patients with severe agitation resulting from PDIT. METHODS: This is a retrospective, observational study enrolling consecutive patients who presented for medical attention at a large outdoor EDMF over a period of eight days on two consecutive weekends in the summer of 2017. The EDMF had an estimated attendance of 40,000 per weekend. A medical tent was set up on-site; patients were managed by a team of EMS providers, nurses and emergency physicians. Medications used, adverse events and the need for repeat dosing were abstracted from prehospital care reports. RESULTS: Over the course of eight days, 1081 of 1186 patients who were evaluated in the medical tent had a recorded chief complaint. 274 of these patients (25.3%) had a chief complaint of altered mental status. In patients presenting with AMS, 68 patients (24.8%) had severe agitation that was treated with dissociative-dose (≥4 mg/kg) intramuscular ketamine. The mean initial dose of ketamine was 308 mg. There were four serious adverse events (5.9%): Two patients (2.9%) had copious hypersalivation treated with atropine, one patient (1.5%) had transient apnea requiring assisted ventilation, and one patient (1.5%) was intubated and transported to the hospital. 42 patients (61.8%) required redosing of calming medications. All patients who received ketamine except the single patient who was intubated and transported were observed in the medical tent until resolution of symptoms and discharged back to the festival. CONCLUSION: In this cohort of festival attendees who developed stimulant-induced severe agitation and were treated with dissociative-dose ketamine, serious adverse events occurred in 5.9% of patients including one patient who was intubated.

Post-traumatic Stress Disorder in Family-witnessed Resuscitation of Emergency Department Patients.

INTRODUCTION: Family presence during emergency resuscitations is increasingly common, but the question remains whether the practice results in psychological harm to the witness. We examine whether family members who witness resuscitations have increased post-traumatic stress disorder (PTSD) symptoms at one month following the event. METHODS: We identified family members of critically ill patients via our emergency department (ED) electronic health record. Patients were selected based on their geographic triage to an ED critical care room. Family members were called a median of one month post-event and administered the Impact of Event Scale-Revised (IES-R), a 22-item validated scale that measures post-traumatic distress symptoms and correlates closely with Diagnostic and Statistical Manual of Mental Disorders-IV criteria for post-traumatic stress disorder (PTSD). Family members were placed into two groups based on whether they stated they had witnessed the resuscitation (FWR group) or not witnessed the resuscitation (FNWR group). Data analyses included chi-square test, independent sample t-test, and linear regression controlling for gender and age. RESULTS: A convenience sample of 423 family members responded to the phone interview: 250 FWR and 173 FNWR. The FWR group had significantly higher mean total IES-R scores: 30.4 vs 25.6 (95% confidence interval [CI], -8.73 to -0.75; P<.05). Additionally, the FWR group had significantly higher mean score for the subscales of avoidance (10.6 vs 8.1; 95% CI, -4.25 to -0.94; P<.005) and a trend toward higher score for the subscale of intrusion (13.0 vs 11.4; 95% CI, -3.38 to .028; P = .054). No statistical significant difference was noted between the groups in the subscale of hyperarousal (6.95 vs 6.02; 95% CI, -2.08 to 0.22; P=.121). All findings were consistent after controlling for age, gender, and immediate family member (spouse, parent, children, and grandchildren). CONCLUSION: Our results suggest that family members who witness ED resuscitations may be at increased risk of PTSD symptoms at one month. This is the first study that examines the effects of family visitation for an unsorted population of very sick patients who would typically be seen in the critical care section of a busy ED.

Comparison of Oral Ibuprofen and Acetaminophen with Either Analgesic Alone for Pediatric Emergency Department Patients with Acute Pain.

BACKGROUND: Ibuprofen (Motrin; Johnson & Johnson) and acetaminophen (APAP, paracetamol) are the most commonly used analgesics in the pediatric emergency department (ED) for managing a variety of acute traumatic and nontraumatic painful conditions. The multimodal pain management of using a combination of ibuprofen plus acetaminophen has the potential to result in greater analgesia. OBJECTIVE: We compared the analgesic efficacy of a combination of oral ibuprofen plus acetaminophen with either analgesic alone for pediatric ED patients with acute pain. METHODS: We performed a randomized, double-blind superiority trial assessing and comparing the analgesic efficacy of a combination of oral ibuprofen (10 mg/kg dose) plus acetaminophen (15 mg/kg per dose) to either analgesic alone for the treatment of acute traumatic and nontraumatic pain in the pediatric ED. Primary outcomes included a difference in pain scores among the three groups at 60 min. RESULTS: We enrolled 90 patients (30 per group). The difference in mean pain scores at 60 min between acetaminophen and combination groups was 0.30 (95% confidence interval [CI] -0.84 to 1.83); between ibuprofen and combination groups was -0.33 (95% CI -1.47 to 0.80); and between acetaminophen and ibuprofen groups was 0.63 (95% CI -0.54 to 1.81). Reductions in pain scores from baseline to 60 min were similar for all patients in each of the three groups. No adverse events occurred in any group. CONCLUSIONS: We found similar analgesic efficacy of oral ibuprofen and acetaminophen in comparison with each analgesic alone for short-term treatment of acute pain in the pediatric ED, but the trial was underpowered to demonstrate the analgesic superiority of the combination of oral ibuprofen plus acetaminophen in comparison with each analgesic alone.

Does Orally-Administered Radiocontrast Impair Ultrasound Image Quality in Pediatric Patients?

INTRODUCTION: It is commonly assumed that orally-administered radiocontrast material (ORC) preceding abdominal ultrasound (US) performance can obscure image quality and potentially impair diagnostic accuracy when assessing patients with abdominal pain. Due to this concern, ORC administration per protocol for computed tomography (CT) is often delayed until after US performance, potentially contributing to prolonged length of stay in the emergency department (ED) in patients with concern for abdominal pathology. The objective of this study was to evaluate whether early administration of ORC in children with abdominal pain receiving abdominal CT for possible appendicitis obscures subsequent abdominal US image quality. METHODS: We designed a prospective observational study of children <18 years of age presenting to a pediatric ED with abdominal pain who were set to receive ORC prior to obtaining an abdominal CT. These patients received a point-of-care ultrasound (POCUS) of the abdomen to assess the abdominal aorta and right lower quadrant (RLQ) structures (psoas muscle and iliac vessels) pre- and post-ORC administration. Images were compared independently by two blinded emergency US-certified physician-assessors for quality, specifically to determine whether ORC obscured the anatomical structures in question. RESULTS: A total of 17 subjects were enrolled, and each subject had two POCUS studies of the abdomen, one pre- and one post-ORC administration looking to visualize the anatomy of the RLQ and abdominal aorta in both studies. Statistical analysis showed no significant differences in mean values of POCUS image quality scoring by two blinded US-trained physician-assessors for either RLQ structures or abdominal aorta when performed pre- and post-administration of ORC. CONCLUSION: Early ORC administration in children with abdominal pain does not adversely affect image quality of a subsequently performed abdominal US. Patients who may require abdominal CT to determine the etiology of abdominal pain can receive early administration of ORC prior to US performance to help minimize ED length of stay without impairing US diagnostic accuracy.

Administration of Nebulized Ketamine for Managing Acute Pain in the Emergency Department: A Case Series.

Ketamine administration in sub-dissociative doses in the emergency department (ED) results in effective pain relief in patients with acute traumatic and non-traumatic pain, chronic pain, and opioid-tolerant pain. This case series describes five adult ED patients who received nebulized ketamine for predominantly acute traumatic pain. Three patients received nebulized ketamine at 1.5 milligrams per kilogram (mg/kg) dose, one patient at 0.75 mg/kg, and one patient at 1 mg/kg. All five patients experienced a decrease in pain from the baseline up to 120 minutes. The inhalation route of ketamine delivery via breath-actuated nebulizer may have utility for managing pain in the ED.

Association of ultrasound-related interruption during cardiopulmonary resuscitation with adult cardiac arrest outcomes: A video-reviewed retrospective study.

OBJECTIVES: To determine the association of focused transthoracic echocardiography (ECHO) related interruption during cardiopulmonary resuscitation (CPR) with patient outcomes in the Emergency Department (ED). METHODS: This was a retrospective, single center, cohort study, conducted in an urban community teaching ED. Eligible study subjects were adult patients in the ED with sustained cardiac arrest. Exclusion criteria include traumatic cardiac arrest and age less than 18. All resuscitations were video recorded and were subsequently reviewed by 2 study investigators. The no-flow time from chest compression interruption was analyzed using video review and separated into ECHO-related and non-ECHO related. Our primary outcome was patient survival to hospital discharge and the secondary outcome was the rate of return of spontaneous circulation (ROSC). Multivariate logistic regression analyses were performed to examine the associations between independent variables and outcomes. RESULTS: From January 2016 to May 2017, a total of 210 patients were included for final analysis. The median total no-flow time observed on video was 99.5 s (IQR: 54.0-160.0 s). Among these, a median of 26.5 s (IQR: 0.0-59.0 s) was ECHO-related and a median of 60.5 s (IQR: 34.0-101.9) was non-ECHO-related. The ECHO-related no-flow time between 77 and 122 s (OR: 7.31, 95 % confidence interval [CI]: 1.59-33.59; p-value = 0.01) and ECHO-related interruption ≦ 2 times (OR: 8.22, 95% CI: 1.51-44.64; p-value = 0.01) were positively associated with survival to hospital discharge. ECHO-related interruption ≦ 2 times (OR: 5.55, 95% CI: 2.44-12.61; p-value < 0.001) was also positively associated with ROSC. CONCLUSION: Short ECHO-related interruption during CPR was positively associated with ROSC and survival to hospital discharge. While ECHO can be a valuable diagnostic tool during CPR, the no-flow time associated with ECHO should be minimized.