1. Yan JW, McLeod SL, Iansavitchene A. Ketamine-Propofol Versus Propofol Alone for Procedural Sedation in the Emergency
Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2015 Sep;22(9):1003-13. doi: 10.1111/acem.12737. Epub 2015 Aug
CONCLUSIONS: The premise of combining ketamine with propofol is based on the many synergies that theoretically exist between these two agents. In this study, K-P had a lower frequency of adverse respiratory events in patients undergoing PSA in the ED compared to propofol alone. PMID: 26292077
Comments: Ketofol allows us to use less propofol, which is associated with a risk of apnea. In this SR of 6 RCTs, the incidence of adverse respiratory events was lower in the combined ketamine-propofol group. There was no difference in other outcomes, such as time to discharge. I use this combination when I need sedation with pain control and muscle relaxation, such as in a hip dislocation reduction. Otherwise, ketamine alone is predictable and safe for most patients.
2. Sin B, Ternas T, Motov SM. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015 Mar;22(3):251-7. doi: 10.1111/acem.12604. Epub 2015 Feb 25.
CONCLUSIONS: Four RCTs with methodologic limitations failed to provide convincing evidence to either support or refute the use of subdissociative-dose ketamine for acute pain control in the ED. PMID: 25716117
Comments: Some of the RCTs found ketamine was superior to morphine for analgesia, but overall the effect was similar.
3. Rinderknecht AS, Mittiga MR, Meinzen-Derr J et al. Factors associated with oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department: findings from multivariable analyses of video review data. Acad Emerg Med. 2015 Apr;22(4):431-40. doi: 10.1111/acem.12633. Epub 2015 Mar 16.
CONCLUSIONS: For children 24 months of age or younger undergoing RSI in a PED, respiratory indication for intubation, esophageal intubation, and duration of laryngoscopy (both individual and cumulative) were associated with desaturation; the number of attempts was not. Interventions to limit attempt duration in the youngest children may improve the safety of RSI. PMID: 25779855
Comments: Children have a smaller functional residual capacity and are quicker to desaturate even with adequate preoxygenation. This video review found the above factors were associated with increased risk of desaturation during intubation. Some of the factors associated with desaturation are pretty obvious - like intubating the esophagus instead of the trachea. The notable aspect of this study is the duration of attempts (over 30 seconds), not number of attempts most strongly correlated with desaturation. Get in and look, and get out and bag if you can't see. Then adjust your technique and take another look once well oxygenated.
1. Shopp JD, Stewart LK, Emmett TW et al. Findings From 12-lead Electrocardiography That Predict Circulatory Shock From Pulmonary Embolism: Systematic Review and Meta-analysis. Acad Emerg Med. 2015 Oct;22(10):1127-37. doi: 10.1111/acem.12769. Epub 2015 Sep
CONCLUSIONS: This systematic review and meta-analysis revealed 10 studies, including 3,007 patients with acute PE, that demonstrate that six findings of RV strain on 12-lead ECG (heart rate > 100 beats/min, S1Q3T3, complete RBBB, inverted T waves in V1-V4, ST elevation in aVR, and atrial fibrillation) are associated with increased risk of circulatory shock and death. PMID: 26394330
Comments: We know elevated BNP and troponin correlate with worse outcome in PE, but does ECG predict hemodynamic collapse? The above ECG findings are positively associated with shock from PE. If you see these, advocate for ICU admission for these patients.
2. Mahler SA, Miller CD, Litt HI et al. Performance of the 2-hour accelerated diagnostic protocol within the American College of Radiology Imaging Network PA 4005 cohort. Acad Emerg Med. 2015 Apr;22(4):452-60. doi: 10.1111/acem.12621. Epub 2015 Mar 24.
CONCLUSIONS: In this first North American application of the ADAPT strategy, sensitivity for MACE within 30 days was 83.9%. One missed adverse event was a MI, with the remainder representing coronary revascularizations. The effect of missing revascularization events needs further investigation. PMID: 25810343
Comments: ADAPT had high sensitivity in an Asian population. However, the sensitivity is too low to use this protocol as a screening test for patients with ACS, at least in this US-based cohort.
3. Schuh S, Chan K, Langer JC et al. Properties of serial ultrasound clinical diagnostic pathway in suspected appendicitis and related computed tomography use. Acad Emerg Med. 2015 Apr;22(4):406-14. doi: 10.1111/acem.12631. Epub 2015 Mar 24.
CONCLUSIONS: The serial US clinical diagnostic pathway in suspected appendicitis has an acceptable diagnostic accuracy that is significantly higher than that of the initial US and results in few CT scans. This approach appears most useful in children with equivocal initial US, in whom the majority of negative cases were identified at clinical reassessment and appendicitis was diagnosed by interval US
or surgical consultation in most study patients. PMID: 25808065
Comments: If ultrasound is non-diagnostic but the clinical exam remains suspicious for appendicitis, CT is usually the next step. But this results in greater radiation exposure. In this study, patients were followed serially and ultrasound was repeated if the clinical exam was still concerning. This resulted in a high sensitivity (97%, 95%CI = 94% - 100%) and very low usage of CT. If your pediatric surgeon is willing to admit for observation, serial exams, and possible repeat ultrasound, this is a viable strategy to rule out appendicitis.
1. Poonai N, Paskar D, Konrad SL et al. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014 Nov;21(11):1183-92. doi: 10.1111/acem.12509.
CONCLUSIONS: The use of opioids in undifferentiated acute abdominal pain in children is associated with no difference in pain scores and an increased risk of mild side effects. However, there is no increased risk of perforation or abscess. The overall quality of evidence is low, suggesting the need for larger, high-quality trials that are powered to detect both serious complications of appendicitis and determine the most efficacious opioid dosing for children. PMID: 25377394
Comments: Opioids use in acute abdominal pain does not mask serious surgical pathology. Pain was likely not improved in these studies because of under-dosing.
Clinical Prediction Rules