Nebulized Ketamine Used for Managing Ankle Fracture in the Prehospital Emergency Setting: A Case Report.

INTRODUCTION: Acute traumatic limb injury is a common complaint of patients presenting to the emergency department (ED). Ketamine is an effective analgesic administered via intravenous (IV), intranasal (IN), intramuscular (IM), and nebulized routes in the ED. It has also been used in the prehospital setting via IV, IM, and IN routes. Recent studies have proposed the prehospital use of nebulized ketamine via breath-actuated nebulizer (BAN) as a noninvasive and effective method of analgesic delivery, as well as an alternative to opioid analgesia. CASE REPORT: We present a case of a patient with right ankle fracture after a 12-foot fall who subsequently received 0.75 milligrams per kilogram of nebulized ketamine via BAN in the prehospital setting. The patient reported improvement of pain from 8/10 to 3/10 on the pain scale without need for additional pain medication during prehospital transport. This report supports the use of nebulized ketamine via BAN in the prehospital setting for acute traumatic limb injuries. CONCLUSION: The use of nebulized ketamine via BAN in the prehospital setting may be an effective analgesic option for the management of patients with acute traumatic limb injuries, particularly in those with difficult IV access, where mucosal atomization devices are not accessible, or where opioid-sparing treatments are preferable.

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.

Cation Short-Range Ordering of MgAl2O4 and NiAl2O4 Spinel Oxides at High Temperatures via In Situ Neutron Total Scattering.

Complex oxides that adopt the isometric spinel structure (AB2O4) are important for numerous technological applications and are relevant for certain geological processes, which involve exposure to extreme environments such as high pressures and temperatures. Recent studies have shown that the changes to the spinel structure caused by these environments are complex and depend on the material length scale under consideration. In this study, we have expanded this approach to the behavior of spinels under high temperatures. In situ neutron total scattering experiments, coupled with pair distribution function analysis, performed on two spinel compositions with various levels of pre-existing disorder (MgAl2O4 and NiAl2O4) revealed that both compositions trend to a state of maximum disorder where the A and B cations are randomly distributed among the two available sites. Temperature-induced cation inversion, conventionally understood as an exchange of cations on the A and B sites, is locally expressed as an atomic rearrangement to a tetragonal symmetry, a correlation that is retained up to the maximum temperature studied (1000 °C). A complex thermal expansion behavior is revealed wherein the oxide materials expand heterogeneously at the level of coordination polyhedra with an apparent dependence on bond strength.

Defining the Structural Stability Field of Disordered Fluorite Oxides.

Fluorite-structured oxides constitute an important class of materials for energy technologies. Despite their high level of structural symmetry and simplicity, these materials can accommodate atomic disorder without losing crystallinity, making them indispensable for uses in environments with high temperature, changing chemical compositions, or intense radiation fields. In this contribution, we present a set of simple rules that predict whether a compound may adopt a disordered fluorite structure. This approach is closely aligned with Pauling's rules for ionic crystal structures and Goldschmidt's rules for ionic substitution.

Predicting short-range order and correlated phenomena in disordered crystalline materials.

Disordered crystalline materials are used in a wide variety of energy-related technologies. Recent results from neutron total scattering experiments have shown that the atomic arrangements of many disordered crystalline materials are not random nor are they represented by the long-range structure observed from diffraction experiments. Despite the importance of disordered materials and the impact of disorder on the expression of physical properties, the underlying fundamental atomic-scale rules of disordering are not currently well understood. Here, we report that heterogeneous disordering (and associated structural distortions) can be understood by the straightforward application of Pauling's rules (1929). This insight, corroborated by first principles calculations, can be used to predict the short-range, atomic-scale changes that result from structural disordering induced by extreme conditions associated with energy-related applications, such as high temperature, high pressure, and intense radiation fields.

Disorder in Ho2Ti2-x Zr x O7: pyrochlore to defect fluorite solid solution series.

Pyrochlore (A2B2O7) is an important, isometric structure-type because of its large variety of compositions and structural derivatives that are generally related to different disordering mechanisms at various spatial scales. The disordering is key to understanding variations in properties, such as magnetic behavior or ionic conduction. Neutron and X-ray total scattering methods were used to investigate the degree of structural disorder in the Ho2Ti2-x Zr x O7 (x = 0.0-2.0, Δx = 0.25) solid solution series as a function of the Zr-content, x. Ordered pyrochlores (Fd3̄m) disorder to defect fluorite (Fm3̄m) via cation and anion disordering. Total scattering experiments with sensitivity to the cation and anion sublattices provide unique insight into the underlying atomic processes. Using simultaneous Rietveld refinement (long-range structure) and small-box refinement PDF analysis (short-range structure), we show that the series undergoes a rapid transformation from pyrochlore to defect fluorite at x ≈ 1.2, while the short-range structure exhibits a linear increase in a local weberite-type phase, C2221, over the entire composition range. Enthalpies of formation from the oxides determined using high temperature oxide melt solution calorimetry support the structural data and provide insight into the effect of local ordering on the energetics of disorder. The measured enthalpies of mixing are negative and are fit by a regular solution parameter of W = -31.8 ± 3.7 kJ mol-1. However, the extensive short-range ordering determined from the structural analysis strongly suggests that the entropies of mixing must be far less positive than implied by the random mixing of a regular solution. We propose a local disordering scheme involving the pyrochlore 48f to 8a site oxygen Frenkel defect that creates 7-coordinated Zr sites contained within local weberite-type coherent nanodomains. Thus, the solid solution is best described as a mixture of two phases, with the weberite-type nanodomains triggering the long-range structural transformation to defect fluorite after accumulation above a critical concentration (50% Ti replaced by Zr).

A2TiO5 (A = Dy, Gd, Er, Yb) at High Pressure.

The structural evolution of lanthanide A2TiO5 (A = Dy, Gd, Yb, Er) at high pressure is investigated using synchrotron X-ray diffraction. The effects of A-site cation size and of the initial structure are systematically examined by varying the composition of the isostructural lanthanide titanates and the structure of dysprosium titanate polymorphs (orthorhombic, hexagonal, and cubic), respectively. All samples undergo irreversible high-pressure phase transformations, but with different onset pressures depending on the initial structure. While each individual phase exhibits different phase transformation histories, all samples commonly experience a sluggish transformation to a defect cotunnite-like (Pnma) phase for a certain pressure range. Orthorhombic Dy2TiO5 and Gd2TiO5 form P21am at pressures below 9 GPa and Pnma above 13 GPa. Pyrochlore-type Dy2TiO5 and Er2TiO5 as well as defect-fluorite-type Yb2TiO5 form Pnma at ∼21 GPa, followed by Im3̅m. Hexagonal Dy2TiO5 forms Pnma directly, although a small amount of remnants of hexagonal Dy2TiO5 is observed even at the highest pressure (∼55 GPa) reached, indicating kinetic limitations in the hexagonal Dy2TiO5 phase transformations at high pressure. Decompression of these materials leads to different metastable phases. Most interestingly, a high-pressure cubic X-type phase (Im3̅m) is confirmed using high-resolution transmission electron microscopy on recovered pyrochlore-type Er2TiO5. The kinetic constraints on this metastable phase yield a mixture of both the X-type phase and amorphous domains upon pressure release. This is the first observation of an X-type phase for an A2BO5 composition at high pressure.

Inversion in Mg1-xNixAl2O4 Spinel: New Insight into Local Structure.

A wide variety of compositions adopt the isometric spinel structure (AB2O4), in which the atomic-scale ordering is conventionally described according to only three structural degrees of freedom. One, the inversion parameter, is traditionally defined as the degree of cation exchange between the A- and B-sites. This exchange, a measure of intrinsic disorder, is fundamental to understanding the variation in the physical properties of different spinel compositions. Based on neutron total scattering experiments, we have determined that the local structure of Mg1-xNixAl2O4 spinel cannot be understood as simply being due to cation disorder. Rather, cation inversion creates a local tetragonal symmetry that extends over sub-nanometer domains. Consequently, the simple spinel structure is more complicated than previously thought, as more than three parameters are needed to fully describe the structure. This new insight provides a framework by which the behavior of spinel can be more accurately modeled under the extreme environments important for many geophysics and energy-related applications, including prediction of deep seismic activity and immobilization of nuclear waste in oxides.