Paramedics apply cervical spine rule successfully

The Canadian C-Spine rule – a decision instrument designed to clinically rule out important cervical spine injuries in alert patients – was successfully and safely applied by Canadian paramedics in a study of 1949 patients. Any misinterpretation erred on the side of safety.
This important work could ultimately result in less stress, discomfort, and wasting of ambulance resources and time for this large subgroup of pre-hospital patients.

The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
Ann Emerg Med. 2009 Nov;54(5):663-671

emergence with ketamine overstated

A prospective study of 746 children sedated in the emergency department with iv or im ketamine revealed 2.1% may have experienced ‘emergence delirium’ although the authors concede this was difficult to define. In contrast, 291 (38%) reported pleasant altered perceptions. Follow up revealed at least one nightmare in the following weeks in 3.4% of patients, which may be well under the rate reported in the normal unsedated paediatric population.

What is the nature of the emergence phenomenon when using intravenous or intramuscular ketamine for paediatric procedural sedation?
Emerg Med Australas. 2009 Aug;21(4):315-22

Ambulance transport induces stress

Plasma levels of adrenaline and noradrenaline increased signficantly in patients with acute coronary syndrome during ambulance transportation – a finding in keeping with studies on normal volunteers. I wonder how much more of an effect helicopter retrieval might have?

Emergency ambulance transport induces stress in patients with acute coronary syndrome
Emerg Med J. 2009 Jul;26(7):524-8.

Ketamine lowered ICP in brain-injured kids

• Ventilated children between the ages of 1 and 16 with traumatic brain injury and elevated intracranial pressure (ICP) were given ketamine and effect on cerebral perfusion pressure (CPP) and ICP was measured. Ketamine decreased ICP while maintaining blood pressure and CPP. These results refute the notion that ketamine increases ICP. The authors conclude: “Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations”
  Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension
  J Neurosurg Pediatr. 2009 Jul;4(1):40-6 (Full text)

Etomidate versus ketamine for rapid sequence intubation

Finally a well designed blinded randomised controlled trial on this subject. 0.3 mg/kg etomidate was compared with 2mg/kg ketamine for RSI in 655 patients requiring emergency intubation in the pre-hospital, emergency department, or intensive care unit environments. No difference was observed in intubation conditions or the primary endpoint of maximum SOFA score in the first three days, although the etomidate group had a higher rate of adrenal insufficiency as defined by response to an ACTH test.

Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial.
Lancet. 2009 Jul 25;374(9686):293-300