The American journal of emergency medicine
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Randomized Controlled Trial Clinical Trial
Ketamine in the treatment of bronchospasm during mechanical ventilation.
The effect of ketamine on bronchospasm during mechanical ventilation was evaluated in a prospective, placebo-controlled, double-blind trial. Fourteen mechanically ventilated patients with bronchospasm were randomly allocated to either ketamine 1 mg/kg or saline placebo. In the ketamine-treated patients, PO2 increased from 10.5 (+/- 0.5) kPa to 16.4 (+/- 2.7) kPa (P < .05), whereas PO2 in the placebo-treated patients remained unchanged. ⋯ The pulmonary stethoscopic bronchospasm improved immediately after the administration of ketamine, whereas the thoracic compliance remained unchanged. In conclusion, the ketamine-treated patients showed an improvement by stethoscopic examination, in PO2 and in PCO2, suggesting that ketamine might be useful in the treatment of bronchospasm during mechanical ventilation. However, further studies are required to decide whether ketamine should be considered the drug of choice in patients with severe bronchospasm during ventilator treatment.
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Subcutaneous emphysema is an unusual complication of bronchiolitis. The investigators describe a patient with bronchiolitis who developed extensive subcutaneous emphysema. ⋯ Review of the literature shows a multitude of causes of subcutaneous emphysema. The vast majority of cases resolve without intervention.
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To identify differences between correctly diagnosed appendicitis and misdiagnosed cases that resulted in litigation between 1982 and 1989 retrospective review of malpractice claims was conducted. A total of emergency department (ED) charts at the time of the initial ED visit were reviewed and compared with 66 concurrent controls. Missed cases appeared less acutely ill, had fewer complaints of right lower quadrant pain, received fewer rectal examinations, received intramuscular (IM) narcotic pain medication for undiagnosed abdominal pain or symptoms, and more often received an ED discharge diagnosis of gastroenteritis. ⋯ Data were analyzed using the Pearson's chi 2 Test, Mann-Whitney U Test, and stepwise discriminant analysis. Significance was defined as P < or = .05. Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions.
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The objective was to determine the association between the performance rates of pediatric advanced life-support procedures, intubation and vascular access, by emergency medicine technician-paramedics (EMT-P), and introduction of an EMT-P pediatric advanced life support (PALS) clinical course. Prehospital EMT-P care records from January 1990 to December 1991 were retrospectively reviewed to determine endotracheal intubation and vascular access performance rates. These rates were compared with intubation and vascular access performance rates by EMT-Ps from January 1983 to June 1985. ⋯ Vascular access, intravenous or intraosseous, was established in 130 (73%) of the children; no attempt was made in 14 children. The vascular access performance rate was 64% for children younger than 18 months of age and 79% for children > or = 18 months old. Intubation performance rates of EMT-Ps before the EMT-P PALS clinical course (January 1983 to June 1985) were 48% for children younger than 18 months of age and 85% for children > or = 18 months old.(ABSTRACT TRUNCATED AT 250 WORDS)