Use of Transparent Film Dressing to Facilitate Mask Ventilation in Bearded Patients.

BACKGROUND: Mask ventilation is a critical airway procedure made more difficult in the bearded patient. OBJECTIVE: We sought to objectively investigate whether application of transparent cling film (TegadermTM; 3M Healthcare, Maplewood, MN) over a beard in the operating room improves the quality of mask ventilation. METHODS: This was a randomized crossover trial of bearded adult patients undergoing surgery. Exclusions included emergency procedures, American Society of Anesthesiologists physical status classification > 3, a documented history of difficult mask ventilation, and body mass index (BMI) > 50. Transparent cling film was applied snuggly over the lower face with a 2- to 3-cm slit cut over the mouth after anesthesia induction. Mask ventilation performed by an anesthesiology resident, anesthesiology assistant, or anesthesiology assistant student and standardized to a thenar-eminence grip without use of airway adjuncts in a sniffing position. Standardized pressure-controlled ventilations were delivered via an anesthesia machine. A calibrated external pneumotachograph was used to measure delivered and returned tidal volumes from which raw and percent air leak were calculated. A clinically significant difference was determined a priori to be 15%, necessitating the enrollment of 25 patients. RESULTS: Of 25 subjects, 96% were men with a mean ± SD BMI of 29.3 ± 6. Seventeen (68%) had a full beard and 8 (32%) had a partial beard. The mean ± SD leakage was 48% ± 26% for transparent cling film vs. 46% ± 20% without its application, which was not significantly different (p = 0.67). CONCLUSIONS: The use of transparent cling film to cover the lower half of the bearded face did not have an impact on the ability or efficacy to perform mask ventilation in the operating room setting. CLINICALTRIALS: gov, Number NCT04274686.

Evidence-Based Guideline for Prehospital Airway Management.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Management of Hantavirus Cardiopulmonary Syndrome in Critical Care Transport: A Review.

In 1993, the Southwest found itself staring down a disease then known as "unexplained adult respiratory syndrome." During the outbreak, 12 of 23 known patients died. What we now recognize as hantavirus cardiopulmonary syndrome still remains a rare and deadly disease. Although no cure exists, modern supportive techniques such as extracorporeal membrane oxygenation have increased survival among these patients. Early diagnosis has become the primary factor in patient survival. The initial presentation of hantavirus is similar to acute respiratory distress syndrome, necessitating a high index of suspicion to afford the patient the best chance of survival. Diagnosis is further complicated by prolonged and nonspecific incubation periods making it difficult to pinpoint an exposure. Familiarizing oneself with common clinical presentations, diagnostic strategies, and testing is the best way to increase patient survival. Because hantavirus has a predilection for rural areas, transport to a tertiary facility is paramount to provide the resources necessary to care for these complex patients. Rapid sequence intubation, although common in airway-compromised patients, could prove fatal in the setting of the severe hemodynamic instability found in hantavirus cardiopulmonary syndrome. Anticipation of significant pressor use and fluid administration could likely mean the difference in patient mortality during transport.

Management of Acute Upper Gastrointestinal Bleeding in Critical Care Transport.

Upper gastrointestinal bleeding is a relatively common and life-threatening condition encountered by critical care transport crews. It is of paramount importance that transport crews understand the underlying pathophysiology of variceal and nonvariceal gastrointestinal bleeding as well as the nuanced management of this patient population. This article reviews the current clinical evidence on initial resuscitation, medical management, and advanced invasive therapies (such as balloon tamponade devices) that transport crews should be familiar with to manage these patients. In addition, we present a novel method of continuous balloon pressure monitoring of balloon tamponade devices that is applicable to the transport environment.

Paramedic-Performed Carotid Artery Ultrasound Heralds Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Case Report.

Point-of-Care Ultrasound (POCUS) has been demonstrated to have multiple applications in the care of critically ill and injured patients, especially given its portability and ease of use. These characteristics of POCUS make it ideal for use in the prehospital environment as well. We present a case that highlights a novel application of ultrasound in the prehospital management of out-of-hospital cardiac arrest (OHCA).

Management of Respiratory Distress and Failure in Morbidly and Super Obese Patients During Critical Care Transport.

Morbidly and super obese patients are a unique patient population that presents critical care transport providers with unique clinical and logistical challenges in the setting of respiratory distress and failure. These patients are more likely to have chronic respiratory issues at baseline, unique anatomic and physiologic abnormalities, and other comorbidities that leave them poorly able to tolerate respiratory illness or injury. This requires specialized understanding of their respiratory mechanics as well as how to tailor standard treatment modalities, such as noninvasive ventilation, to meet their needs. Also, careful and deliberate planning is required to address the specific anatomic and physiologic characteristics of this population if intubation and mechanical ventilation are needed. Finally, their dimensions and weight also have distinct consequences on transport vehicle considerations. This article reviews the pathophysiology, management, and critical care transport considerations for this unique patient population in respiratory distress and failure.

Rapid Sequence Airway with the Intubating Laryngeal Mask in the Emergency Department.

BACKGROUND: The administration of sedation and neuromuscular blockade to facilitate extraglottic device (EGD) placement is known as rapid sequence airway (RSA). In the emergency department (ED), EGDs are used largely as rescue devices. In select patients, there may be significant advantages to using EGDs over laryngoscopy as the primary airway device in the ED. OBJECTIVE: Our study sought to describe the practice of RSA in the ED, including rates of successful oxygenation, ventilation, and complications from EGD use. METHODS: We identified patients in the ED between 2007 and 2017 who underwent RSA with the LMA® Fastrach™ (hereafter termed ILMA; Teleflex Medical Europe Ltd., Athlone, Ireland) placed as the first definitive airway management device. A trained abstractor performed chart and video review of the cases to determine patient characteristics, physician use of the ILMA, indication for ILMA placement, success of oxygenation and ventilation, success of intubation, and complications related to the device. RESULTS: During the study period, 94 patients underwent RSA with the ILMA. Of those, 93 (99%) were successfully oxygenated and ventilated, and when intubation was attempted, 89% were able to be intubated through the ILMA. The incidence of vomiting and aspiration was 1% and 3%, respectively. There were 30 different attending physicians who supervised RSA and the median number was 2 per physician in the 10-year study period. CONCLUSION: The practice of RSA with the ILMA in the ED is associated with a high rate of successful oxygenation, ventilation, and intubation with infrequent complications, even when performed by physicians with few experiences in the approach.

Accuracy and Reliability of a Disposable Vascular Pressure Device for Arterial Pressure Monitoring in Critical Care Transport.

OBJECTIVE: Arterial catheterization is a commonly performed procedure in intensive care units to guide the management of critically ill patients who require precise hemodynamic monitoring; however, this technology is not always available in the transport setting because of cumbersome and expensive equipment requirements. We compared the accuracy and reliability of a disposable vascular pressure device (DVPD) with the gold standard (ie, the transducer pressure bag invasive arterial monitoring system) used in intensive care units to determine if the DVPD can be reliably used in place of the traditional pressure transducer setup. METHODS: This study was a single-center, prospective, observational study performed in the adult intensive care unit of a large academic university hospital. A convenience cohort of hemodynamically stable, adult critically ill patients with femoral, brachial, or radial arterial catheters was recruited for this study. The Compass pressure device (Centurion Medical Products, Williamston, MI) is a disposable vascular pressure-sensing device used to assure venous access versus inadvertent arterial access during central line placement. The DVPD was attached to an in situ arterial catheter and measures the mean intravascular pressure via an embedded sensor and displays the pressure via the integrated LCD screen. Using a 3-way stopcock, the DVPD was compared with the standard arterial setup. We compared the mean arterial pressure (MAP) in the standard setup with the DVPD using Bland-Altman plots and methods that accounted for repeated measures in the same subject. RESULTS: Data were collected on 14 of the 15 subjects enrolled. Five measurements were obtained on each patient comparing the DVPD with the standard arterial setup at 1-minute intervals over the course of 5 minutes. A total of 70 observations were made. Among the 15 subjects, most (10 [67%]) were radial or brachial sites. The average MAP scores and standard deviation values obtained by the standard setup were 83.5 mm Hg (14.8) and 81.1 mm Hg (19.3) using the DVPD. Just over half (51.4%) of the measurements were within a ± 5-mm Hg difference. Using Bland-Altman plotting methods, standard arterial measurements were 2.4 mm Hg higher (95% confidence interval, 0.60-4.1) than with the DVPD. Differences between the 2 devices varied significantly across MAP values. The standard arterial line measurements were significantly higher than the DVPD at low MAP values, whereas the DVPD measurements were significantly higher than the standard arterial line at high MAP values. CONCLUSION: The DVPD provides a reasonable estimate of MAP and may be suitable for arterial pressure monitoring in settings where standard monitoring setups are not available. The DVPD appears to provide "worst-case" values because it underestimates low arterial blood pressure and overestimates high arterial blood pressure. Future trials should investigate the DVPD under different physiological conditions (eg, hypotensive patients, patients with ventricular assist devices, and patients on extracorporeal membrane oxygenation), different patient populations (such as pediatric patients), and in different environments (prehospital, air medical transport, and austere locations).

Troubleshooting Hypoxemia After Placement of an Extraglottic Airway.

The case presented here highlights the feasibility of using an extraglottic airway device as a conduit for delivering high levels of lifesaving positive end expiratory pressure (PEEP), as well as other means of combating recalcitrant hypoxia. The case also highlights the merit of an approach to the hypoxic patient with an in-situ extraglottic airway device based not only on deciding if the device is functioning to maintain a patent airway, but also, simultaneously considering the patient's physiology. A 71 year old male suffered an out-of-hospital cardiac arrest. Part of his resuscitation included placement of a dual-balloon extraglottic airway device by EMS. He was hypoxic, but the device seemed to be providing for a patent airway without an air leak. There was also a favorable end-tidal carbon dioxide waveform. The flight team chose to the leave the device in place. PEEP was up-titrated to 17 cmH20 without issue. Sigh breaths, as well as breath holds, were also able to be delivered. The patient's hypoxia improved over the course of the patient's transport, and he ultimately did well.

Apneic nasal oxygenation and safe apnea time during pediatric intubations by learners.

BACKGROUND: Apneic nasal oxygenation (ApOx) prolongs the time to desaturation during intubation of adult patients, but there is limited prospective evidence for apneic oxygenation in pediatric patients. AIMS: We hypothesized that ApOx during operating room intubation of pediatric patients by inexperienced learners would prolong the interval before desaturation. METHODS: This prospective observational study compared intubation data for 196 pediatric surgical patients intubated by learners under baseline practice (no nasal cannula), to 160 patients enrolled after adoption of routine apneic nasal cannula oxygenation at 5 L/min. The primary outcome was elapsed time between anesthetic induction and pulse oximetry (SpO2 ) falling to 95, if ever. RESULTS: Nasal cannula oxygenation during intubation by learners delayed desaturation to SpO2 95 (risk ratio for this event before intubation 0.05, 95% CI 0.03-0.09; P < 0.0001). CONCLUSIONS: Apneic oxygenation via nasal cannula during intubation of pediatric surgical patients prolongs time before desaturation, thus extending the safe interval for airway management by learners.

Emergency Department Management of Out-of-Hospital Laryngeal Tubes.

STUDY OBJECTIVE: Laryngeal tubes are commonly used by emergency medical services (EMS) personnel for out-of-hospital advanced airway management. The emergency department (ED) management of EMS-placed laryngeal tubes is unknown. We seek to describe ED airway management techniques, success, and complications of patients receiving EMS laryngeal tubes. METHODS: Using a keyword text search of ED notes, we identified patients who arrived at our ED with a laryngeal tube from 2010 through 2017. We performed structured chart and video reviews for all eligible patients. In our ED, emergency physicians perform all airway management, and there is no protocol dictating airway management for patients arriving with a laryngeal tube. Using descriptive methods, we report the techniques, success, and complications of ED airway management. RESULTS: We analyzed data on 647 patients receiving out-of-hospital laryngeal tubes, including 472 (73%) with cardiac arrest from medical causes, 75 (21%) with cardiac arrest from trauma, and 100 (15%) with other conditions. For 580 patients (89%), emergency physicians exchanged the laryngeal tube for a definitive airway in the ED. Of the 67 patients not intubated in the ED, 66 died in the ED without further airway management. Of the 580 patients intubated in the ED, orotracheal intubation was the first method attempted for 578 (>99%) and was successful on the first attempt for 515 of 578 (89%). Macintosh video laryngoscopy (88% of initial attempts) and a bougie (68% of initial attempts) were commonly used adjuncts. For 345 of 578 patients (60%), the laryngeal tube was removed before intubation attempts. For 112 of 578 patients (19%), the first intubation attempt occurred with the deflated laryngeal tube left in place. Three patients (<1%) required a surgical airway. CONCLUSION: In this cohort, emergency physicians successfully exchanged an out-of-hospital laryngeal tube for an endotracheal tube, using commonly available airway management techniques. ED clinicians should be familiar with techniques for exchanging out-of-hospital extraglottic airways for an endotracheal tube.

Preliminary Report: Comparing Aspiration Rates between Prehospital Patients Managed with Extraglottic Airway Devices and Endotracheal Intubation.

INTRODUCTION: There has been a shift from endotracheal intubation (ETI) toward extraglottic devices (EGDs) for prehospital airway management. A concern exists that this may lead to more frequent cases of aspiration. METHODS: This was a retrospective study using a prehospital quality assurance database. Patients were assigned to groups based on the method that ultimately managed their airways (EGD or ETI). Cases with documented blood/emesis obscuring the airway were considered inevitable aspiration cases and excluded. Aspiration was defined by the radiology report within 48 hours. RESULTS: A total of 104 EGD and 152 ETI patients were identified. Aspiration data were available for 67 EGD and 94 ETI cases. Of those, 8 EGD and 3 ETI cases had blood/emesis obscuring the airway and were excluded as planned. After exclusions, there were 5 EGD and 11 ETI cases in which aspiration was later diagnosed (EGD aspiration rate = 8%, ETI aspiration rate = 12%; χ2: P = .359; relative risk = .841; 95% confidence interval, .329-2.152). CONCLUSION: In this small quality assurance database, aspiration rates were not significantly different for prehospital patients managed with an EGD versus ETI.

Incidence and Duration of Continuously Measured Oxygen Desaturation During Emergency Department Intubation.

STUDY OBJECTIVE: Desaturation during intubation has been associated with serious complications, including dysrhythmias, hemodynamic decompensation, hypoxic brain injury, and cardiac arrest. We seek to determine the incidence and duration of oxygen desaturation during emergency department (ED) rapid sequence intubation. METHODS: This study included adult rapid sequence intubation cases conducted between September 2011 and July 2012 in an urban, academic, Level I trauma center ED. We obtained continuous vital signs with BedMasterEX data acquisition software. Start and completion times of rapid sequence intubation originated from nursing records. We defined oxygen desaturation as (1) cases exhibiting SpO2 reduction to less than 90% if the starting SpO2 was greater than or equal to 90%, or (2) a further reduction in SpO2 in cases in which starting SpO2 was less than 90%. We used multivariable logistic regression to predict oxygen desaturation during rapid sequence intubation. RESULTS: During the study period, there were 265 rapid sequence intubation cases. The study excluded 99 cases for failure of electronic data acquisition, inadequate documentation, or poor SpO2 waveform during rapid sequence intubation, and excluded cases managed by anesthesia providers, leaving 166 patients in the analysis. After preoxygenation, starting SpO2 was greater than 93% in 124 of 166 cases (75%) and SpO2 was less than 93% in the remaining 46 cases. Oxygen desaturation occurred in 59 patients (35.5%). The median duration of desaturation was 80 seconds (interquartile range 40, 155). Multivariable analysis demonstrated that oxygen desaturation was associated with preintubation SpO2 less than 93% (odds ratio [OR] 5.1; 95% confidence interval (CI) 2.3 to 11.0), multiple intubation attempts (>1 attempt) (OR 3.4; 95% CI 1.4 to 6.1), and rapid sequence intubation duration greater than 3 minutes (OR 2.7; 95% CI 1.2 to 6.1). CONCLUSION: In this series, 1 in 3 patients undergoing ED rapid sequence intubation experienced oxygen desaturation for a median duration of 80 seconds. Preintubation saturation less than 93%, multiple intubation attempts, and prolonged intubation time are independently associated with oxygen desaturation. Clinicians should use strategies to prevent oxygen desaturation during ED rapid sequence intubation.

Radiographic evaluation of carotid artery compression in patients with extraglottic airway devices in place.

OBJECTIVES: Extraglottic airway devices (EADs) are now commonly placed for airway management of critically ill or injured patients, particularly by emergency medical services providers in the out-of-hospital setting. Recent literature has suggested that EADs may cause decreased cerebral blood flow due to compression of the arteries of the neck by the devices' inflated cuffs. METHODS: The authors identified a cohort of 17 patients presumed to be hemodynamically stable with EADs in place who underwent radiographic imaging of the neck. These studies were reviewed by a neuroradiologist to determine if mechanical compression of the carotid arteries was present. RESULTS: None of the 17 cases reviewed had radiographically evident mechanical compression of the carotid artery. CONCLUSIONS: Until further studies are performed in which cerebral perfusion is evaluated prospectively in both hemodynamically stable and unstable human subjects, there is insufficicent evidence to recommend against the use of extraglottic airways in the emergency setting on the basis of carotid artery compression.

One-year outcomes of out-of-hospital administration of intravenous glucose, insulin, and potassium (GIK) in patients with suspected acute coronary syndromes (from the IMMEDIATE [Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care] Trial).

The Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency care Trial of very early intravenous glucose-insulin-potassium (GIK) for acute coronary syndromes (ACS) in out-of-hospital emergency medical service (EMS) settings showed 80% reduction in infarct size at 30 days, suggesting potential longer-term benefits. Here we report 1-year outcomes. Prespecified 1-year end points of this randomized, placebo-controlled, double-blind, effectiveness trial included all-cause mortality and composites including cardiac arrest, mortality, or hospitalization for heart failure (HF). Of 871 participants randomized to GIK versus placebo, death occurred within 1 year in 11.6% versus 13.5%, respectively (unadjusted hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.57 to 1.23, p = 0.36). The composite of cardiac arrest or 1-year mortality was 12.8% versus 17.0% (HR 0.71, 95% CI 0.50 to 1.02, p = 0.06). The composite of hospitalization for HF or mortality within 1 year was 17.2% versus 17.2% (HR 0.98, 95% CI 0.70 to 1.37, p = 0.92). The composite of mortality, cardiac arrest, or HF hospitalization within 1 year was 18.1% versus 20.4% (HR 0.85, 95% CI 0.62 to 1.16, p = 0.30). In patients presenting with suspected ST elevation myocardial infarction, HRs for 1-year mortality and the 3 composites were, respectively, 0.65 (95% CI 0.33 to 1.27, p = 0.21), 0.52 (95% CI 0.30 to 0.92, p = 0.03), 0.63 (95% CI 0.35 to 1.16, p = 0.14), and 0.51 (95% CI 0.30 to 0.87, p = 0.01). In patients with suspected acute coronary syndromes, serious end points generally were lower with GIK than placebo, but the differences were not statistically significant. However, in those with ST elevation myocardial infarction, the composites of cardiac arrest or 1-year mortality, and of cardiac arrest, mortality, or HF hospitalization within 1 year, were significantly reduced.

Development of an EMS curriculum.

Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010. Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implementation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360° feedback, written and oral testing, and retrospective chart reviews. This paper describes a curriculum that is congruent with the current EMS core content, as well as providing a 12-month format to deploy the curriculum in an EMS fellowship program. Key words: curriculum; education; emergency medical services; fellowships and scholarships.

Out-of-hospital administration of intravenous glucose-insulin-potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial.

CONTEXT: Laboratory studies suggest that in the setting of cardiac ischemia, immediate intravenous glucose-insulin-potassium (GIK) reduces ischemia-related arrhythmias and myocardial injury. Clinical trials have not consistently shown these benefits, possibly due to delayed administration. OBJECTIVE: To test out-of hospital emergency medical service (EMS) administration of GIK in the first hours of suspected acute coronary syndromes (ACS). DESIGN, SETTING, AND PARTICIPANTS: Randomized, placebo-controlled, double-blind effectiveness trial in 13 US cities (36 EMS agencies), from December 2006 through July 31, 2011, in which paramedics, aided by electrocardiograph (ECG)-based decision support, randomized 911 (871 enrolled) patients (mean age, 63.6 years; 71.0% men) with high probability of ACS. INTERVENTION: Intravenous GIK solution (n = 411) or identical-appearing 5% glucose placebo (n = 460) administered by paramedics in the out-of-hospital setting and continued for 12 hours. MAIN OUTCOME MEASURES: The prespecified primary end point was progression of ACS to myocardial infarction (MI) within 24 hours, as assessed by biomarkers and ECG evidence. Prespecified secondary end points included survival at 30 days and a composite of prehospital or in-hospital cardiac arrest or in-hospital mortality, analyzed by intent-to-treat and by presentation with ST-segment elevation. RESULTS: There was no significant difference in the rate of progression to MI among patients who received GIK (n = 200; 48.7%) vs those who received placebo (n = 242; 52.6%) (odds ratio [OR], 0.88; 95% CI, 0.66-1.13; P = .28). Thirty-day mortality was 4.4% with GIK vs 6.1% with placebo (hazard ratio [HR], 0.72; 95% CI, 0.40-1.29; P = .27). The composite of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with placebo (OR, 0.48; 95% CI, 0.27-0.85; P = .01). Among patients with ST-segment elevation (163 with GIK and 194 with placebo), progression to MI was 85.3% with GIK vs 88.7% with placebo (OR, 0.74; 95% CI, 0.40-1.38; P = .34); 30-day mortality was 4.9% with GIK vs 7.7% with placebo (HR, 0.63; 95% CI, 0.27-1.49; P = .29). The composite outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo (OR, 0.39; 95% CI, 0.18-0.82; P = .01). Serious adverse events occurred in 6.8% (n = 28) with GIK vs 8.9% (n = 41) with placebo (P = .26). CONCLUSIONS: Among patients with suspected ACS, out-of-hospital administration of intravenous GIK, compared with glucose placebo, did not reduce progression to MI. Compared with placebo, GIK administration was not associated with improvement in 30-day survival but was associated with lower rates of the composite outcome of cardiac arrest or in-hospital mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00091507.

Low-dose ketamine for analgesia in the ED: a retrospective case series.

OBJECTIVES: The aim of this study was to describe the use and effect of low-dose ketamine (LDK) for analgesia in the emergency department (ED). METHODS: A chart review was performed to identify all adult patients who received LDK for analgesia in our ED. Cases were identified by pharmacy record of ketamine administration. Low-dose ketamine was defined as the administration of 0.1 to 0.6 mg/kg of ketamine for pain control. Use of ketamine during procedural sedation was excluded. Data were analyzed descriptively. RESULTS: Thirty-five cases in which patients received LDK in the ED for a 2-year period were identified. Doses ranged from 5 to 35 mg. Administration was intravenous in 30 (86%) of 35 cases and intramuscular in 5 (14%) of 35 cases. Opioids were administered before or coadministered with LDK in 32 (91%) of 35 cases, and in the remaining 3 cases, opioids were used before the patient came to the ED. Improvement in pain was observed in 19 (54%) of 35 cases in which patients received LDK. Pain scores did not improve in 8 (23%) of 35 cases. Insufficient data were available to determine LDK effect for 8 (23%) of 35 cases. No significant adverse events were identified in any of the 35 cases. CONCLUSIONS: The administration of LDK in the ED may be a safe and effective adjunct for analgesia in some patients. However, prospective randomized controlled trials are needed before widespread use of LDK for analgesia in the ED can be recommended.