The American journal of emergency medicine
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The safe and effective use of ketamine for sedation/analgesia by emergency physicians has been validated in the medical literature. Nonetheless, arbitrary restrictions of this medication to anesthesia practitioners have prohibited emergency physician use in some locations. We explore the scientific evidence related to the use of ketamine by emergency physicians for sedation/analgesia, the history of sedation, the operational definitions of conscious sedation and dissociative anesthesia, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) related standards. We conclude that ketamine sedation/ analgesia offers many specific advantages for emergency patients and that it is safely administered by emergency physicians in the appropriately monitored setting.
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Review Case Reports
Subarachnoid hemorrhage following permissive hypercapnia in a patient with severe acute asthma.
In this article, we describe a case of a subarachnoid hemorrhage (SAH) in an acute severe asthma patient following mechanical hypoventilation. A 49-year-old man was admitted to an Intensive Care Unit with an acute exacerbation of asthma. After 3 days of mechanical ventilation (hypercapnia and normoxaemia), it was noted that his right pupil was fixed, dilated, and unreactive to light. ⋯ Since normoxaemic hypercapnia has been associated with absence, or less cerebral edema, we considered additional factors to explain cerebral edema and intracranial hypertension causes. Thus, intrathoracic pressures due to patient's efforts by forcibly exhaling, or during mechanical ventilation, would further increase intracranial pressure by limiting cerebral venous drainage. This case emphasizes the fact that patients with acute severe asthma who have developed profoundly hypercarbic without hypoxia before or during mechanical ventilation, may have raised critical intracranial pressure.
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Succinylcholine has long been the favored neuromuscular blocking agent for emergent airway management because of its rapid onset, dependable effect, and short duration. However, it has a plethora of undesirable side effects, ranging from the inconsequential to the catastrophic. When patients requiring tracheal intubation present with potential contraindications to succinylcholine use, the emergency physician will need to substitute a rapid-onset nondepolarizing neuromuscular blocking agent, such as rocuronium or mivacurium. An understanding of the pharmacology of these agents is essential.