J Emerg Med
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Paraphimosis is an acute urological emergency occurring in uncircumcised males that can lead to strangulation of the glans and painful vascular compromise. Ketamine has been used in the emergency department (ED) as an anesthetic agent for procedural sedation, and when administrated in a sub-dissociative dose (low dose) at 0.1-0.3 mg/kg, ketamine has been utilized in the ED and prehospital settings for pain control as an adjunct and as an alternative to opioid, as well as for preprocedural sedation. This report details the case of a pediatric patient who presented to our Pediatric ED with paraphimosis and had his procedural pain treated with ketamine administrated via a breath-actuated nebulizer (BAN). ⋯ This case report illustrates the potential use of ketamine via BAN to effectively achieve minimal sedation for a procedure in pediatric patients in the ED. The patient was a 15-year-old boy admitted to the Pediatric ED complaining of groin pain due to paraphimosis. The patient was given 0.75 mg/kg of nebulized ketamine via BAN, and 15 min after the medication administration the pain score was reduced from 5 to 1 on the numeric pain rating scale. The patient underwent a successful paraphimosis reduction without additional analgesic or sedative agents 20 min after the administration of nebulized ketamine. The patient was subsequently discharged home after 60 min of monitoring, with a pain score of 0. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The use of nebulized ketamine via BAN might represent a viable, noninvasive way to provide a mild sedative and be an effective analgesic option for managing a variety of acute painful conditions and procedures in the pediatric ED.
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Acute pain management in the emergency department (ED) is a challenging task, more so in pain due to malignancy. Opioids have life-threatening side effects in ED patients, along with the risk of dependency. Erector spinae plane block (ESPB) is a recently described plane block technique with ease of performance and minimal side effects, making it suitable for emergency settings. ⋯ A 62-year-old male patient recently diagnosed with cholangiocarcinoma presented to the ED with severe right upper abdominal pain. There was no pain relief with high doses of analgesics. ESPB was administered at T7 vertebrae level. The patient's Defense and Veteran Pain Rating Scale score reduced from 8/10 pre-procedure to 3/10 within 15 min, and 2/10 1 h after the procedure. He reported that he had an uninterrupted pain-free sleep after 4 days. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ESPB is a novel regional analgesia that may help in management of uncontrolled severe pain not relieved with analgesics in patients with cholangiocarcinoma in the ED.
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Completing an emergency medicine (EM) away rotation is integral to matching successfully into an EM residency program. The demand for EM away rotations (ARs) drives students to submit numerous applications without evidence-based recommendations to guide stakeholders on the approach or number to submit. ⋯ This study showed that, as a whole, students received one away rotation offer for every four to five applications submitted. It clarified factors contributing to increased EM away rotation application submissions and associated stressors inherent in the application experience. Our findings offer insights to inform advising recommendations. They also suggest that stakeholders consider standardizing the process and improve communication over spot availability and application status.
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Hydroxychloroquine overdose is rare but potentially lethal. Hydroxychloroquine overdose symptoms are characterized by central nervous system toxicity, cardiac toxicity, and hypokalemia. Recommended treatment consists of epinephrine, high-dose diazepam, and careful potassium repletion. Few pediatric hydroxychloroquine overdoses have been reported. ⋯ We describe a 14-year-old girl who ingested 10 g (172 mg/kg) of hydroxychloroquine. She developed tachycardia, hypotension, and hypokalemia. She was intubated and treated with diazepam and epinephrine infusions and potassium supplementation. Her serum hydroxychloroquine concentration obtained 10 h after ingestion was 13,000 ng/mL (reference range 500-2000 ng/mL). The patient made a full medical recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pediatric hydroxychloroquine overdoses are reported rarely, and the toxic and lethal doses of hydroxychloroquine ingestion have not been established. This case of a teenaged patient who ingested 10 g of hydroxychloroquine and survived provides additional information that may be used to help establish toxic and lethal doses of ingestion.
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Observational Study
Chest Compression Fraction Alone Does Not Adequately Measure Cardiopulmonary Resuscitation Quality in Out-of-Hospital Cardiac Arrest.
High-quality cardiopulmonary resuscitation in out-of-hospital cardiac arrest is important for increased survival and improved neurological outcome. Chest compression fraction measures the proportion of time chest compressions are given during a cardiac arrest resuscitation. Chest compression fraction has not been compared with the quality of chest compressions delivered at the recommended rate and depth of 100-120/min and 2.0-2.4 inches, respectively. ⋯ Chest compression fraction is not associated with compressions in target for rate and depth for out-of-hospital cardiac arrest cardiopulmonary resuscitation.