- Email: [email protected]
A pilot study using low-dose intravenous ketamine as an analgesic for acute pain in adults
RESEARCH FORUM ABSTRACTS
ii ber of attempts to start SW, use of SW, final diagnosis, and disposition. SWs that were not used for either medication or fluid administration or which were not placed preoperatively were considered "prophylactic placement/not used." All charts of enrolled patients were reviewed for diagnosis and to verify use of SW (chart review was considered correct when discrepancies existed). Analysis was limited to descriptive statistics Results: Data were obtained on the p}acement of 630 SWs (representing approximately one third of all SWs placed in the ED during the study period). Of these, 54% of the patients were female and the mean age was 42 years (range, 4 weeks to 100 years). The most common chief complaint was abdominal pain (17%), chest pain (13%), fever/infection (10%), and vaginal bleeding (4%). The decision to place an SW was made by the nurse in 184 (29%) of the cases The median number of attempts to place an SW was 1 with an interquartile range of L to 1. The most common final diagnosis was fever/infection (14%), chest pain (13%), abdominal pain (I2%), vomiting/diarrhea (10%), and vaginal bleeding (4%). Two hundred eighty-seven (46%) patients were admitted. SWs were used in 461 (73%) patients (medication administration 297, hydration 296, preoperatively 21). SWs were used in 461 (73%) patients. Conclusion: SWs placed in the ED were used nearly three fourths of the time Clinical decisionmaking regarding SW placement in the ED should be further studied
49,Analgesic Pilot Study Using Low-Dose Intravenous Ketumine as an for Acute Pain in Adults Smith DC/BaystateMedical Center, Springfield. MA Study objectives: Ketamine has been widely used for sedation of pediatnc patients undergoing painful procedures in the emergency department. Its use for deep sedation and analgesia in adults has been limited by its propensity to induce emergence reactions. This pilot study evaluated the efficacy of low-dose intravenous ketamine as an analgesic in adults using an experimental pain model. Methods: This was a double-blind, block-randomized, placebo-controlled trial conducted on healthy volunteers. Using a transcutaneous peripheral nerve stimulator, participants were subjected to an escalating electrical stimulus (10 to 50 mA) delivered as a train-of-four through electrodes placed on the eadobe. After each stimulus was produced, subjects were asked to mark their perceived pain response on a standard 10cm visual analog scale (VAS). The series of stimuli was terminated if the subject found the pain intolerable. After a series of stimuli was delivered in the control phase, subjects performed the digit span subtest of the revised Wechsler Adult Intelligence Scale (WAIS-R) examination. Participants were then randomized to receive either ketamine (0.25 mg/kg) or an equivalent volume of placebo (normal saline solution). Two minutes after the infusion of drug or placebo, the testing procedure was repeated. Blood pressure, pulse, and oxygen saturation were recorded every 3 minutes. Subjects were interviewed 48 hours after the study. Differences in VAS at each stimulus were calculated (VAS,5) as were differences in WAIS scores (WA1SA) before and after administration of drug/placebo. Multivariate analysis of variance was used to compare the VASA at each stimulus setting. WAISA and hemodynamie data were analyzed using unpaired t tests. Results: Seventeen subjects (ketamine 8, placebo 9) were studied. At higher stimulus levels, subjects in the ketamine group reported significantly less pain as measured by the VAS. At a stimulus of 45 mA, the mean VASA for the ketamine group was 2.5 cm compared with 0.8 cm for the placebo group (difference 1.7 cm, 95% confidence interval [CI] 0.1 to 3.3 cm, P=.04). At a stimulus of 50 mA, the mean VASA for the ketamine group was 2.6 cm and 0.3 cm for the placebo group (difference 2.3 cm, 95% CI 0 to 4.5 cm, P=.05). The mean WAISA for the ketamine group was 2.5 compared with 43.8 for the placebo group (difference 3.3, 95% CI 0.4 to 4.1, P=.02). Pulse rate was significantly higher in the ketamine group: 99 beats/min and 93 beats/rain, at 3 and 6 minutes, respectively, compared with the placebo group: 72 beats/min and 74 beats/min, respectively (P>.01). Systolic blood pressure was also significantly higher for these time points in the ketamine group: 150 m m Hg ketamine versus 125 placebo (P=.04 for 3 minutes, P=.02 for 6 minutes). No significant alterations in diastolic blood pressure or oxygen saturation were noted, and no significant changes in vital signs were noted after 6 minutes. The following other effects were reported by subjects after receiving ketamine: nausea 25% (P=.47), sleepiness 63% (P=.03), vertigo'dizziness 38% (P=.20), auditory alterations 38% (P= 20). No subjects reported any adverse effects beyond the immediate study period. Conclusion: This pilot study on the use of low-dose ketamine in adults suggests that it provides significant pain relief as measured in this model. A number of minor side effects were noted, but none appear to have effects beyond the immediate period
OCTOBER 1999. PART 2 34:4 ANNALSOF EMERGENCYMEDICINE
of administration Alterations in the method of administration may obviate some of these effects without altering ketamine's effectiveness as an analgesic.
250
Concordance Between Prehospital Notification by EMS and Actual Patient Presentation W'dh Relation to the Allocation of Hospital Resources
Carlson TE, Oster N, ShashalyJ/Mount Sinai School of Medicine. Elmhurst Hospital Center, New York, NY Study objectives: To evaluate concordance between emergency medical serwces (EMS) notification reports and patient presentation, and identify any site or patient factors contributing to imprecise information relayed. Methods: A prospective analysis of EMS notifications was conducted from October 1. 1998, through December 31. 1999, in a busy metropolitan Level I trauma center. A logbook for recording history, vital signs, basic life support (BLS)/advanced life support (At.S), was located near our "red phone," where all advanced EMS calls are accepted. The mage nurse recorded the EMS notifications on the logbook templates and delivered the information to the provider receiving the patient The providers were instructed to determine concordance, based not on correct diagnoses but on whether the notification (1) was consistent with patient presentation (ie, stability), (2) placed an unexpected burden on ED resources and, (3) contributed positively to the patient treatment plan and outcome. The project staff evaluated the log book information, EMS run sheet, and the patient ED chart to track concordance. Subject selection was limited only to "red phone" notifications regardless of disease or injury Results: A total of 183 EMS notifications were reviewed with a total 84% of recordings accurate vath patient presentation. Although the majority of notifications were consistent, there was a noticeable lack of concordance of EMS notifications involving multiple casualties. Of the 5 incidents involving multiple casualties (3 or more patients on scene), only 7 of 24 patients presenting (29%) had concordance with EMS notification Single patients with trauma (motor vehicle accidents, stab wounds, gunshot wounds), as well as medical conditions (cardiovascular accident, myocardial infarction. acute pulmonary edema), were consistently accurate with concordance rates ranging in the 90th percentile. Conclusion: Precise advanced notification by EMS remains an essential component to proper allocation of hospital resources, patient care and continuous quality improvement. Overall, EMS notifications during this study were favorably concordant, with the exception of those involving multiple casualties at the scene. In April 1999, a follow-up study was initiated to further evaluate the notification protocol and critically examine the factors that lead to accurate or inaccurate notifications.
251
Prehospital gseofaSternellotraosseouslnfusion Device
HorwoodBT, Adams J. Tiffany BR, PollackCV, Adams B, Scalzi R, SucherM/Maricopa Medical Center, Phoenix,AZ Study objective: Reliable, high-flow vascular access is arguably the single most valuable tool in the resuscitation of the acutely ill patient, but achieving that access quickly in moribund patients can be difficult Tibial intraosseous infusion (IOl) is a widely accepted route of access in the pediatric population, but is not feasible in adults because of the thickness of the tibial cortex. The adult sternum is an appropriate site for IO1 access wath its relatively thin cortex and highly vascular marrow space. The Food and Drug Administration has recently approved the first sternal 101 device in the United States, the FAST-1 (Pyng Medical Corp, Vancouver, BC, Canada). We report on our initial prehospital experience with this de,ace. Methods: Paramedics in a limited geographic area and the emergency department personnel at the 2 hospitals potentially receiving study patients were trained by the investigators in the insertion and removal of the device. Patients were eligible for the stud)" if they were in nontraumatic cardiac arrest and the initial attempt at peripheral intravenous access had failed. A single FAST-1 insertion attempt was made. If successful, the 101 line was used as the primary line for drugs and fluids, with further attempts at peripheral access at the paramedics discretion. After arrival at the receiving hospital, the paramedic was asked to record basic information about the patient and the insertion attempt, drugs infused via the FAST-1 device, and approximate flow rates. A successful attempt was defined as infusion of fluid through the device without evidence of infiltration. The study was approved by the institutional review boards of the 2 base station hospitals and the Arizona Department of Health Services. Results: Between December 1. 1998, and May 12, 1999, there were 37 FAST-I
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ii ber of attempts to start SW, use of SW, final diagnosis, and disposition. SWs that were not used for either medication or fluid administration or which were not placed preoperatively were considered "prophylactic placement/not used." All charts of enrolled patients were reviewed for diagnosis and to verify use of SW (chart review was considered correct when discrepancies existed). Analysis was limited to descriptive statistics Results: Data were obtained on the p}acement of 630 SWs (representing approximately one third of all SWs placed in the ED during the study period). Of these, 54% of the patients were female and the mean age was 42 years (range, 4 weeks to 100 years). The most common chief complaint was abdominal pain (17%), chest pain (13%), fever/infection (10%), and vaginal bleeding (4%). The decision to place an SW was made by the nurse in 184 (29%) of the cases The median number of attempts to place an SW was 1 with an interquartile range of L to 1. The most common final diagnosis was fever/infection (14%), chest pain (13%), abdominal pain (I2%), vomiting/diarrhea (10%), and vaginal bleeding (4%). Two hundred eighty-seven (46%) patients were admitted. SWs were used in 461 (73%) patients (medication administration 297, hydration 296, preoperatively 21). SWs were used in 461 (73%) patients. Conclusion: SWs placed in the ED were used nearly three fourths of the time Clinical decisionmaking regarding SW placement in the ED should be further studied
49,Analgesic Pilot Study Using Low-Dose Intravenous Ketumine as an for Acute Pain in Adults Smith DC/BaystateMedical Center, Springfield. MA Study objectives: Ketamine has been widely used for sedation of pediatnc patients undergoing painful procedures in the emergency department. Its use for deep sedation and analgesia in adults has been limited by its propensity to induce emergence reactions. This pilot study evaluated the efficacy of low-dose intravenous ketamine as an analgesic in adults using an experimental pain model. Methods: This was a double-blind, block-randomized, placebo-controlled trial conducted on healthy volunteers. Using a transcutaneous peripheral nerve stimulator, participants were subjected to an escalating electrical stimulus (10 to 50 mA) delivered as a train-of-four through electrodes placed on the eadobe. After each stimulus was produced, subjects were asked to mark their perceived pain response on a standard 10cm visual analog scale (VAS). The series of stimuli was terminated if the subject found the pain intolerable. After a series of stimuli was delivered in the control phase, subjects performed the digit span subtest of the revised Wechsler Adult Intelligence Scale (WAIS-R) examination. Participants were then randomized to receive either ketamine (0.25 mg/kg) or an equivalent volume of placebo (normal saline solution). Two minutes after the infusion of drug or placebo, the testing procedure was repeated. Blood pressure, pulse, and oxygen saturation were recorded every 3 minutes. Subjects were interviewed 48 hours after the study. Differences in VAS at each stimulus were calculated (VAS,5) as were differences in WAIS scores (WA1SA) before and after administration of drug/placebo. Multivariate analysis of variance was used to compare the VASA at each stimulus setting. WAISA and hemodynamie data were analyzed using unpaired t tests. Results: Seventeen subjects (ketamine 8, placebo 9) were studied. At higher stimulus levels, subjects in the ketamine group reported significantly less pain as measured by the VAS. At a stimulus of 45 mA, the mean VASA for the ketamine group was 2.5 cm compared with 0.8 cm for the placebo group (difference 1.7 cm, 95% confidence interval [CI] 0.1 to 3.3 cm, P=.04). At a stimulus of 50 mA, the mean VASA for the ketamine group was 2.6 cm and 0.3 cm for the placebo group (difference 2.3 cm, 95% CI 0 to 4.5 cm, P=.05). The mean WAISA for the ketamine group was 2.5 compared with 43.8 for the placebo group (difference 3.3, 95% CI 0.4 to 4.1, P=.02). Pulse rate was significantly higher in the ketamine group: 99 beats/min and 93 beats/rain, at 3 and 6 minutes, respectively, compared with the placebo group: 72 beats/min and 74 beats/min, respectively (P>.01). Systolic blood pressure was also significantly higher for these time points in the ketamine group: 150 m m Hg ketamine versus 125 placebo (P=.04 for 3 minutes, P=.02 for 6 minutes). No significant alterations in diastolic blood pressure or oxygen saturation were noted, and no significant changes in vital signs were noted after 6 minutes. The following other effects were reported by subjects after receiving ketamine: nausea 25% (P=.47), sleepiness 63% (P=.03), vertigo'dizziness 38% (P=.20), auditory alterations 38% (P= 20). No subjects reported any adverse effects beyond the immediate study period. Conclusion: This pilot study on the use of low-dose ketamine in adults suggests that it provides significant pain relief as measured in this model. A number of minor side effects were noted, but none appear to have effects beyond the immediate period
OCTOBER 1999. PART 2 34:4 ANNALSOF EMERGENCYMEDICINE
of administration Alterations in the method of administration may obviate some of these effects without altering ketamine's effectiveness as an analgesic.
250
Concordance Between Prehospital Notification by EMS and Actual Patient Presentation W'dh Relation to the Allocation of Hospital Resources
Carlson TE, Oster N, ShashalyJ/Mount Sinai School of Medicine. Elmhurst Hospital Center, New York, NY Study objectives: To evaluate concordance between emergency medical serwces (EMS) notification reports and patient presentation, and identify any site or patient factors contributing to imprecise information relayed. Methods: A prospective analysis of EMS notifications was conducted from October 1. 1998, through December 31. 1999, in a busy metropolitan Level I trauma center. A logbook for recording history, vital signs, basic life support (BLS)/advanced life support (At.S), was located near our "red phone," where all advanced EMS calls are accepted. The mage nurse recorded the EMS notifications on the logbook templates and delivered the information to the provider receiving the patient The providers were instructed to determine concordance, based not on correct diagnoses but on whether the notification (1) was consistent with patient presentation (ie, stability), (2) placed an unexpected burden on ED resources and, (3) contributed positively to the patient treatment plan and outcome. The project staff evaluated the log book information, EMS run sheet, and the patient ED chart to track concordance. Subject selection was limited only to "red phone" notifications regardless of disease or injury Results: A total of 183 EMS notifications were reviewed with a total 84% of recordings accurate vath patient presentation. Although the majority of notifications were consistent, there was a noticeable lack of concordance of EMS notifications involving multiple casualties. Of the 5 incidents involving multiple casualties (3 or more patients on scene), only 7 of 24 patients presenting (29%) had concordance with EMS notification Single patients with trauma (motor vehicle accidents, stab wounds, gunshot wounds), as well as medical conditions (cardiovascular accident, myocardial infarction. acute pulmonary edema), were consistently accurate with concordance rates ranging in the 90th percentile. Conclusion: Precise advanced notification by EMS remains an essential component to proper allocation of hospital resources, patient care and continuous quality improvement. Overall, EMS notifications during this study were favorably concordant, with the exception of those involving multiple casualties at the scene. In April 1999, a follow-up study was initiated to further evaluate the notification protocol and critically examine the factors that lead to accurate or inaccurate notifications.
251
Prehospital gseofaSternellotraosseouslnfusion Device
HorwoodBT, Adams J. Tiffany BR, PollackCV, Adams B, Scalzi R, SucherM/Maricopa Medical Center, Phoenix,AZ Study objective: Reliable, high-flow vascular access is arguably the single most valuable tool in the resuscitation of the acutely ill patient, but achieving that access quickly in moribund patients can be difficult Tibial intraosseous infusion (IOl) is a widely accepted route of access in the pediatric population, but is not feasible in adults because of the thickness of the tibial cortex. The adult sternum is an appropriate site for IO1 access wath its relatively thin cortex and highly vascular marrow space. The Food and Drug Administration has recently approved the first sternal 101 device in the United States, the FAST-1 (Pyng Medical Corp, Vancouver, BC, Canada). We report on our initial prehospital experience with this de,ace. Methods: Paramedics in a limited geographic area and the emergency department personnel at the 2 hospitals potentially receiving study patients were trained by the investigators in the insertion and removal of the device. Patients were eligible for the stud)" if they were in nontraumatic cardiac arrest and the initial attempt at peripheral intravenous access had failed. A single FAST-1 insertion attempt was made. If successful, the 101 line was used as the primary line for drugs and fluids, with further attempts at peripheral access at the paramedics discretion. After arrival at the receiving hospital, the paramedic was asked to record basic information about the patient and the insertion attempt, drugs infused via the FAST-1 device, and approximate flow rates. A successful attempt was defined as infusion of fluid through the device without evidence of infiltration. The study was approved by the institutional review boards of the 2 base station hospitals and the Arizona Department of Health Services. Results: Between December 1. 1998, and May 12, 1999, there were 37 FAST-I
$6 5