J Emerg Med
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Whether acute or chronic, emergency physicians frequently encounter patients reporting pain. It is the responsibility of the emergency physician to assess and evaluate, and if appropriate, safely and effectively reduce pain. Recently, analgesics other than opioids are being considered in an effort to provide safe alternatives for pain management in the emergency department (ED). Opioids have significant adverse effects such as respiratory depression, hypotension, and sedation, to say nothing of their potential for abuse. Although ketamine has long been used in the ED for procedural sedation and rapid sequence intubation, it is used infrequently for analgesia. Recent evidence suggests that ketamine use in subdissociative doses proves to be effective for pain control and serves as a feasible alternative to traditional opioids. This paper evaluates ketamine's analgesic effectiveness and safety in the ED. ⋯ Subdissociative-dose ketamine (low-dose ketamine) is effective and safe to use alone or in combination with opioid analgesics for the treatment of acute pain in the ED. Its use is associated with higher rates of minor, but well-tolerated adverse side effects.
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Chest pain is a common presentation to the emergency department (ED), though the majority of patients are not diagnosed with acute coronary syndrome (ACS). Many patients are admitted to the hospital due to fear of ACS. ⋯ With nonischemic ECG and negative cardiac biomarker, the risk of ACS approaches < 1%. Use of stress test and CCTA for risk stratification of low-risk chest pain patients is controversial. These tests may allow prognostication but do not predict ACS risk beyond ECG and troponin. CCTA may be useful for intermediate-risk patients, though further studies are required.
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Multicenter Study Clinical Trial
Safety and Efficacy of the "Easy Internal Jugular (IJ)": An Approach to Difficult Intravenous Access.
The easy internal jugular (Easy IJ) technique involves placement of a single-lumen catheter in the internal jugular vein using ultrasound guidance. This technique is used in patients who do not have suitable peripheral or external jugular venous access. The efficacy and safety of this procedure are unknown. ⋯ The Easy IJ was inserted successfully in 88% of cases, with a mean time of 4.4 min. Loss of patency, the only complication, occurred in 14% of cases.
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Joint pain caused by acute osteoarthritis (OA) is a common finding in the emergency department. Patients with OA often have debilitating pain that limits their function and ability to complete their activities of daily living. In addition, OA has been associated with a high percentage of arthritis-related hospital admissions and an increased risk of all-cause mortality. Safely managing OA symptoms in these patients can present many challenges to the emergency provider. ⋯ Emergency providers should be aware of the risks and benefits of all treatment options available for acute OA pain, including oral medications, topical preparations, corticosteroid injections, bracing, and physical therapy.
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Over the last decades, dental implants have become increasingly popular in the prosthetic rehabilitation of patients. This has subsequently led to an increase of perioperative complications. Obstruction of the airway as a result of a floor of mouth hematoma after dental implant surgery is a rare but life-threatening complication. ⋯ A 62-year-old man presented to the emergency department with a compromised airway caused by a hematoma in the floor of the mouth that occurred during dental implant surgery in the edentulous anterior mandible. Computed tomography angiography images revealed an elevation of the floor of mouth with subsequent occlusion of the airway. In addition, a perforation of the lingual mandibular cortical plate was observed that was caused by two malpositioned dental implants. Awake fiberoptic intubation was immediately performed, the two malpositioned dental implants were subsequently removed, and the patient was extubated after 3 days. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Perforation of the lingual mandibular cortical plate during dental implant surgery can lead to life-threatening bleeding in the floor of the mouth. This condition can be successfully treated by awake fiberoptic intubation and, if necessary, the malpositioned dental implants can be subsequently removed.