J Emerg Med
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Although intravenous (i.v.) administration of antiepileptic drugs is the preferred route of therapy in status epilepticus, intramuscular (i.m.) delivery may provide a valuable alternative when there are obstacles to venous access. Compared to other treatment options such as rectal drug administration, which is as challenging as the i.v. route in a convulsing patient, the i.m. route is easier and less invasive. The two most commonly used first-line anticonvulsants, diazepam and lorazepam, may be administered i.m., but are absorbed from the i.m. site more slowly than midazolam. ⋯ Because of its water solubility, midazolam is rapidly absorbed from the injection site and has excellent local tolerability. The pharmacodynamic effects of midazolam can be seen within seconds of its administration, and seizure arrest is usually attained within 5 to 10 min. Case reports and a recent randomized trial that demonstrate the successful use of i.m. midazolam in the termination of epileptic seizures are reviewed.
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Randomized Controlled Trial Clinical Trial
A randomized controlled trial of buffered lidocaine for local anesthetic infiltration in children and adults with simple lacerations.
This study assessed the efficacy of buffered lidocaine in children and adults for the repair of simple lacerations. We compared plain lidocaine (PL) with buffered lidocaine (BL) in a prospective, randomized, double-blind, placebo controlled trial. Children had a 10-point pain score assessed by a nurse using predetermined behavior criteria, and a visual analog pain score (VAS) as perceived by the parent. ⋯ In 136 children, the median nurse-rated pain score was 4.5 for both PL and BL. The parent's median VAS was 4.5 for PL and 4.0 for BL. In contrast to previous studies, we conclude that buffered lidocaine does not reduce infiltration pain in children or adults.
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Several case reports and animal studies raise concerns over the risk of aspiration pneumonia when administering activated charcoal (AC) to intubated patients. Therefore, we sought to determine the incidence of aspiration pneumonia in intubated overdose patients who then received AC. We conducted a retrospective review from January 1994 to April 1997 of intubated patients who then received AC. ⋯ The remaining 50 patients, ages 1-64 years, 33% male, overdosing on a large variety of substances, required acute intubation and then received AC. Only two patients of these 50 (4%) with initial negative radiographs developed a new infiltrate after intubation and AC. Administration of AC to intubated overdose patients is associated with a low incidence of aspiration pneumonia.
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A prospective study of Emergency Medicine (EM) residents was conducted over two consecutive 1-month periods at a rural tertiary-care teaching hospital with a residency in EM to evaluate the effect of a 4-h pain management education program on the assessment and management of acute pain in the emergency department (ED). All patients presenting to the ED with an acute, painful condition were eligible to participate in the survey. Patients were excluded if they had taken any pain medication within 4 h of presenting to the ED, or had any condition requiring immediate resuscitation, suspected cardiac pain, or pain from a potential surgical abdomen. ⋯ Only 65% of the patients studied before the EP had significant reduction in their pain scores after 30 min in the ED; after institution of the EP, 92% had a significant reduction in their pain scores at 30 min. Similarly, a significant improvement was seen in the patients' global evaluation of treatment after the educational program was instituted. It appears that the use of a 4-h educational program on pain assessment and management directed toward EM residents in their training can improve their skills at recognizing and treating painful conditions.
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Case Reports
Epidural pneumatosis associated with spontaneous pneumomediastinum: case report and review of the literature.
Epidural pneumatosis rarely has been reported in association with spontaneous pneumomediastinum. We report a case of an asymptomatic 24-year-old male who presented after forceful vomiting with both findings. The patient recovered uneventfully without residual signs or symptoms. We discuss spontaneous pneumomediastinum as well as epidural pneumatosis and review reported cases in the literature.