Emergency medicine journal : EMJ
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The safety of intravenous ketamine in procedural sedation is well described.(1 2) Guidelines produced by NICE(3) and the College of Emergency Medicine(4) are used by Emergency Departments (ED) nationwide. To avoid cannulation, opioids are frequently administered to children intranasally(5), avoiding first-pass metabolism.(6) Intranasal ketamine (INK) is an effective analgesic in children(7) and has been successfully utilised in prehospital and military settings.(8 9) However, a recent survey revealed that INK is not currently in use in UK paediatric EDs.(10)To determine the current level of evidence of the use of INK in procedural sedation in children we developed a clinical scenario and three part question.A 4 year old child presents with a lip laceration. Options for closure are under procedural sedation in the ED or general anaesthetic in theatre. You feel he would be suitable for procedural sedation. Your department's policy is intravenous ketamine. However the child is very upset and you feel the trauma of cannulation will adversely affect quality of sedation. Would INK be an alternative? ⋯ In [children undergoing procedural sedation] does [intranasal ketamine] result in [rapid onset, safe, effective sedation without prolonged recovery]?Using the search strategy outlined in table 1, seven relevant papers were identified.(11-18) RESULTS: EfficacyINK can be successfully used to sedate children for dental procedures at 3-6 mg/kg.(11-13) 5 mg/kg facilitates cannulation prior to induction of anaesthesia.(14-16) An ED based double-blinded RCT compared sedation with 3,6 and 9mg/kg INK(17). The study was small and was terminated early due to high sedation failures.SafetyAll studies demonstrated 3-9 mg/kg INK is safe, with no serious adverse events.EfficiencyAt 3-9mg/kg, time to onset ranged from 3.6-9.4 minutes with recovery time between 30-69 minutes.(11-17) CONCLUSION: An ideal agent for procedural sedation in the Paediatric ED is safe, easily delivered with rapid onset and recovery. The limited but growing evidence supports the use of INK to achieve this, although ideal dose is still unclear. All published studies to date have varying flaws with strict protocols defining adequate sedation and a lack of validated dissociative sedation scale potentially limiting reported success. More studies are emerging with a recent proposal presented to the PERUKI group. INK may still make its way into Paediatric EDs in the not too distant future.
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Randomized Controlled Trial
Comparison of three techniques using the Parkland Formula to aid fluid resuscitation in adult burns.
We performed a randomised study to compare the accuracy and speed of three different techniques (pen and paper, electronic calculator and a novel graphic device: 'nomogram') for calculation of resuscitation fluid requirements for adults in the first 24 h of burn injury, based on the Parkland Formula. We also assessed acceptability of each technique using visual analogue scores and qualitative analysis of free text responses. 28 participants performed 252 calculations using a series of computer generated simulated patient data. For nomogram, electronic calculator, pen and paper: Magnitude of error [low (≥25%), medium (≥50%), high (≥75%)]: [6.0%, 1.2%, 0%], [17.9%, 14.3%, 8.3%], [25%, 16.7%, 9.5%]; p<0.002. ⋯ It is low cost and robust, and provides a rapid means of detecting and preventing the large errors that we have shown can occur when an electronic device is used as the only method of calculation. We therefore suggest that the Parkland Formula nomogram is a suitable method for calculation of resuscitation fluid requirements in adult burns. Fluid requirement should, however, be reviewed frequently, and adjusted to ensure adequate organ perfusion.
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A short cut review was carried out to establish whether therapeutic anticoagulation is required for patients who have an incidental diagnosis of subsegmental pulmonary embolism (PE), which is asymptomatic. 4 studies were relevant to the three-part question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The evidence suggests that patients with clinically unsuspected PE may have better prognostic outcomes than those with symptomatic presentations, especially if the PE is at the sub-segmental level. ⋯ However, this study included patients with cancer and was not restricted to patients with subsegmental PE. Consequently, the clinical bottom line is that level 1 evidence is required to answer this question. In the meantime decisions must continue to be informed by clinical judgment.
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The planning of regional emergency medical services is aided by accurate prediction of urgent ambulance journey times, but it is unclear whether it is appropriate to use Geographical Information System (GIS) products designed for general traffic. We examined the accuracy of a commercially available generic GIS package when predicting emergency ambulance journey times under different population and temporal conditions. ⋯ It is reasonable to estimate emergency ambulance journey times using generic GIS software, but in order to avoid insufficient regional ambulance provision it would be necessary to make small adjustments because of the tendency towards systematic underprediction.
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We sought to identify perceived barriers and facilitators to cardiopulmonary resuscitation (CPR) training and performing CPR among people above the age of 55 years. ⋯ We identified key facilitators and barriers for CPR training and performance in a purposive sample of individuals aged 55 years and older.