Comparison of ketamine-low-dose midozolam with midazolam-fentanyl for orthopedic emergencies: a double-blind randomized trial.

OBJECTIVE: Most of the fractures and dislocations are reduced in the emergency setting. Many drugs are available for procedural sedation and analgesia in the emergency department (ED); however, the adverse effects are still a common problem. The aim of our study was to compare the 2 drug combinations. METHOD: We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED after a traumatic event and required urgent reduction either for a fracture or dislocation. Patients were randomized to midazolam-fentanyl (MF) group or ketamine-low-dose midazolam (KM) group. Hypoxia, duration of hypoxia, need for oxygen, time to onset of sedation, recovery time, pain scores during reduction, and sedation depth were set as primary outcome measures and were recorded. RESULTS: A total of 498 patients who presented to ED with extremity injury and required closed reduction were assessed; 130 of them were approached for eligibility and 69 patients were excluded. The remaining 61 patients were randomized to either KM group (n = 31) or MF group (n = 30). Hypoxia and duration of hypoxia were significantly lower in the KM group compared with the MF group. Patients in the KM group reported significantly lower pain scores during reduction; however, adverse effects were higher compared with MF group. CONCLUSION: Both drug combinations can be effectively used for procedural sedation and analgesia; however, with lower risk for hypoxia and lower pain scores, KM combination stands as a reasonable choice for orthopedic interventions in the emergency unit.

A randomized clinical trial comparing the effect of rapidly infused crystalloids on acid-base status in dehydrated patients in the emergency department.

STUDY OBJECTIVE: To compare the effect of normal saline (NS), lactated Ringer's, and Plasmalyte on the acid-base status of dehydrated patients in the emergency department (ED). METHOD: We conducted a prospective, double-blind, randomized trial of consecutive adult patients who presented to the emergency department with moderate-severe dehydration. Patients were randomly allocated to blindly receive normal saline (NS), lactated Ringer's or Plasmalyte at 20 ml/kg/h for 2 hours. Outcome measures of the study were pH and changes in electrolytes, including serum potassium, sodium, chloride and bicarbonate levels at 0, 60, and 120 minutes in venous blood gas samples. RESULTS: Ninety patients participated in the study and were randomized to NS (30 patients), lactated Ringer's (30 patients) and Plasmalyte (30 patients) groups. Mean age was 48±20 years and 50% (n=45) of the patients were female. All pH values were in the physiological range (7.35-7.45) throughout the study period. In the NS group there was a significant tendency to lower pH values, with pH values of 7.40, 7.37, and 7.36 at 0, 1, and 2 hours respectively. Average bicarbonate levels fell in the NS group (23.1, 22.2, and 21.5 mM/L) and increased in the Plasmalyte group (23.4, 23.9, and 24.4 mM/L) at 0, 1, and 2 hours, respectively. There were no significant changes in potassium, sodium, or chloride levels. CONCLUSIONS: NS, lactated Ringer's, and Plasmalyte have no significant effect on acid-base status and all can be used safely to treat dehydrated patients in the emergency department. However, NS can effect acidosis which might be significant in patients who have underlying metabolic disturbances; thus, its use should be weighed before fluid administration in the ED.

Managing adult patients with infectious diseases in emergency departments: international ID-IRI study.

We aimed to explore factors for optimizing antimicrobial treatment in emergency departments. A single-day point prevalence survey was conducted on January 18, 2020, in 53 referral/tertiary hospitals in 22 countries. 1957 (17%) of 11557 patients presenting to EDs had infections. The mean qSOFA score was 0.37 ± 0.74. Sepsis (qSOFA ≥ 2) was recorded in 218 (11.1%) patients. The mean qSOFA score was significantly higher in low-middle (1.48 ± 0.963) compared to upper-middle (0.17 ± 0.482) and high-income (0.36 ± 0.714) countries (P < 0.001). Eight (3.7%) patients with sepsis were treated as outpatients. The most common diagnoses were upper-respiratory (n = 877, 43.3%), lower-respiratory (n = 316, 16.1%), and lower-urinary (n = 201, 10.3%) infections. 1085 (55.4%) patients received antibiotics. The most-commonly used antibiotics were beta-lactam (BL) and BL inhibitors (n = 307, 15.7%), third-generation cephalosporins (n = 251, 12.8%), and quinolones (n = 204, 10.5%). Irrational antibiotic use and inappropriate hospitalization decisions seemed possible. Patients were more septic in countries with limited resources. Hence, a better organizational scheme is required.