A Comparison of Prehospital Pediatric Analgesic Use of Ketamine and Opioids.

OBJECTIVE/INTRODUCTION: Ketamine is an opioid-alternative used for analgesia in the prehospital setting. There are knowledge gaps regarding its use during emergency medical services (EMS) encounters for pediatric patients. Our objective was to compare pain reduction, adverse events, and prehospital deaths between ketamine and opioids when used for analgesia administered by any route among pediatric patients. METHODS: This was a retrospective review of 9-1-1 EMS records of injured pediatric patients (≤17 years of age) who received ketamine or opioids for analgesia using the ESO Data Collaborative (calendar years 2019-2020). We excluded interfacility transfers, patients receiving both medications, those with EMS clinician impressions indicating behavioral disorders, and those who received medication to facilitate advanced airway placement. EMS narrative review was performed to confirm ketamine use was for analgesia and to identify any unplanned airway placements. We assessed pain score reduction (0-10 ordinal scale) and clinician-documented patient response (improved, unchanged, worsened, unknown). Adverse events were defined as change in vital signs (GCS, SBP, RR, SpO2), bag valve mask ventilation alone, or death. Descriptive statistics were calculated to compare outcomes between groups. RESULTS: Overall, 9,223 patients were included, 190 (2.1%) received ketamine and 9,033 (97.9%) received opioids. Mean age in years was 12.8 [SD 4.0] for ketamine and 12.7 [SD 4.0] for opioids. Patients in both groups experienced pain reduction, and more patients receiving ketamine had EMS clinician reported improvement (93.2% vs. 87.9%, p = 0.03). Ketamine was associated with a greater average reduction in pain score than opioids (mean difference: -4.4 [SD 3.5], and -3.1 [SD 2.8], p < 0.001). Adverse events were rare with few patients receiving ventilatory support following the use of ketamine or opioids, (0, [SD 0.0%] vs. 6 [SD 0.1%], p = 1). There were no unplanned airway placements or prehospital deaths identified. CONCLUSION: We identified similar high rates of pain reduction and rare adverse events among pediatric patients who received ketamine or opioids. A greater pain reduction was noted among patients administered ketamine. Intubation as a result of medication administration did not occur and need for ventilatory assistance was rare.

Prehospital Use of Ketamine versus Benzodiazepines for Sedation among Pediatric Patients with Behavioral Emergencies.

INTRODUCTION: Ketamine is an emerging alternative sedation agent for prehospital management of agitation, yet research is limited regarding its use for children. Our objective was to compare the effectiveness and safety of ketamine and benzodiazepines when used for emergent prehospital sedation of pediatric patients with behavioral emergencies. METHODS: We performed a retrospective review of 9-1-1 EMS records from the 2019-2020 ESO Data Collaborative research datasets. We included patients ≤18 years of age who received ketamine or benzodiazepines for EMS primary and secondary impressions indicating behavioral conditions. We excluded patients with first Glasgow Coma Scale (GCS) scores ≤8, those receiving ketamine or benzodiazepines prior to EMS arrival, those receiving both ketamine and benzodiazepines, and interfacility transfers. Effectiveness outcomes included general clinician assessment of improvement, decrease in GCS, and administration of a subsequent sedative. Safety outcomes included mortality; advanced airway placement; ventilatory assistance without advanced airway placement; or marked sedation (GCS ≤8). Chi-square and t-tests were used to compare the ketamine and benzodiazepines groups. RESULTS: Of 57,970 pediatric patients with behavioral complaints and GCS scores >8, 1,539 received ketamine (13.3%, n = 205) or a benzodiazepine (86.7%, n = 1,334). Most patients were ≥12 years old (89.2%, n = 1,372), predominantly Caucasian (48.3%, n = 744), and were equally distributed by sex (49.7% male, n = 765). First treatment with ketamine was associated with a greater likelihood of improvement (88.8% vs 70.5%, p < 0.001) and a greater average GCS reduction compared to treatment with benzodiazepines (-2.5 [SD:4.0] vs -0.3 [SD:1.7], p < 0.001). Fewer patients who received ketamine received subsequent medication compared to those who received benzodiazepines (12.2% vs 27.0%, p < 0.001). Marked sedation was more frequent with ketamine than benzodiazepines (28.8% vs 2.9%, p < 0.001). Provision of ventilatory support (1.5% vs 0.5%, p = 0.14) and advanced airway placement (1.0% vs 0.2%, p = 0.09) were similar between ketamine and benzodiazepine groups. No prehospital deaths were reported. CONCLUSION: In this pediatric cohort, prehospital sedation with ketamine was associated with greater patient improvement, less subsequent sedative administration, and greater sedation compared to benzodiazepines. Though we identified low rates of adverse events in both groups, ketamine was associated with more instances of marked sedation, which bears further study.

Prehospital Ketamine Use in Pediatrics.

Introduction: Information regarding prehospital ketamine use in the pediatric population is limited as existing literature focuses primarily on critical care and air transport. Our objective was to describe patient characteristics among pediatric EMS patients who received ketamine. Secondarily, we assessed effectiveness, deviation from recommended dosing, and adverse outcomes of pediatric EMS patients who received ketamine.Methods: We conducted a retrospective data review of records from the ESO Data Collaborative for all 9-1-1 transports of pediatric patients (≤ 18 years of age) who received ketamine from 2019-2020. We categorized EMS primary impressions as a proxy for medication indication. We defined effectiveness as paramedic-identified clinical improvement, and pain relief as decrease in pain score ≥2 points between initial and final recording. Descriptive statistics were used to summarize clinical characteristics. Non-parametric Wilcoxon signed-rank test was used to assess change in pain score.Results: Out of 422,968 ground-ambulance pediatric patients, 1,291 received ketamine. They were predominately male (842, 65.2%), teenagers (median age 16, IQR: 13-17), Caucasian (810, 62.7%), and from urban areas (1,041, 80.6%). The most common EMS impressions were related to injuries (810, 62.7%) and behavior disorders (281, 21.8%). Only 980/1,291 (75.9%) had weights and identifiable routes recorded. Most patients (960, 74.4%) received single doses of ketamine, with EMS clinicians reporting improvement in 855 (89.1%) of 960 patients. Among non-behavioral emergency patients, 727/1,010 (72.0%) had pain scores recorded. Pain scores decreased significantly from a median of 8 (IQR: 4-10) to 2 (IQR: 0-6) (p < 0.001) with 59% (429) of 727 patients reporting pain score reductions of 2 or more points. Desaturation (<90% SpO2) events were noted to be minimal (1.8%). A small number (28, 2.2%) received positive pressure ventilation without advanced airway placement. No prehospital deaths were documented.Conclusion: In this large review of pediatric prehospital ketamine use, ketamine was primarily used for analgesia, but was frequently used for other indications. Most patients were observed to improve after ketamine use, with most injured patients reporting decreases in pain scores. We observed few significant adverse events related to ketamine use in this population.

Phenotypic evolution shaped by current enzyme function in the bioluminescent courtship signals of sea fireflies.

Mating behaviours are diverse and noteworthy, especially within species radiations where they may contribute to speciation. Studying how differences in mating behaviours arise between species can help us understand how diversity is generated at multiple biological levels. The bioluminescent courtship displays of cypridinid ostracods (or sea fireflies) are an excellent system for this because amazing variety evolves while using a conserved biochemical mechanism. We find that the evolution of one aspect in this behavioural phenotype-the duration of bioluminescent courtship pulses-is shaped by biochemical function. First, by measuring light production from induced bioluminescence in 38 species, we discovered differences between species in their biochemical reactions. Then, for 16 species for which biochemical, phylogenetic and behavioural data are all available, we used phylogenetic comparative models to show that differences in biochemical reaction are nonlinearly correlated with the duration of courtship pulses. This relationship indicates that changes to both enzyme (c-luciferase) function and usage have shaped the evolution of courtship displays, but that they differentially contribute to these phenotypic changes. This nonlinear dynamic may have consequences for the disparity of signalling phenotypes observed across species, and demonstrates how unappreciated diversity at the biochemical level can lead to inferences about behavioural evolution.

Association of carotid artery atheromatous plaque types with cerebral perfusion.

BACKGROUND: In an attempt to define the association of internal carotid artery atheromatous plaque morphology with potential cerebral ischaemia, we have investigated the relationship of different carotid plaque types with defects in cerebral perfusion. METHODS: In 130 patients requiring surgical correction of internal carotid artery stenoses greater than 70%, defects in cerebral perfusion due to both haemodynamic insufficiency and intracerebral vessel occlusion were identified using single photon emission computed tomography scans (SPECT). Carotid artery plaques in these patients were classified as homogeneous or heterogeneous based on preoperative Doppler Duplex Scanning and on the macroscopic characteristics of the plaques recorded by the surgeon during carotid endarterectomy, with sub-classification into potentially embolus-generating and non- embolus-generating plaques. In individual patients, plaque types were then correlated with the perfusion defects found in the SPECT scans. RESULTS: Of 130 patients, 112 (86%) had cerebral perfusion defects. In 56 asymptomatic patients in the study, 48 (85.7%) had perfusion defects as did 64 (86.5%) of 74 symptomatic patients. Cerebral infarcts were seen in 41 (31.5%). Occlusive infarcts (66%) were twice as frequent as haemodynamic insufficiency infarcts (34%). Eighteen patients with small cerebral infarcts on SPECT scanning gave no medical history of cerebral symptoms. Statistical analysis of the results revealed that there was no statistically identifiable association between carotid plaque type and the generation of cerebral symptoms or infarction. CONCLUSION: This study found that internal carotid plaque morphology has no statistically significant association with perfusion defects, symptoms or cerebral infarction in patients with significant internal carotid artery stenosis. Also, it is suggested that haemodynamic cerebral infarction may be more common that previously believed (34% of infarcts identified in the study). Further, it is suggested that plaque morphology alone is not an indication for carotid endarterectomy.

A novel alternative to open conversion for type 1 endoleak resulting in ruptured aneurysm.

In this article, a novel technique for the treatment of ruptured abdominal aortic aneurysm secondary to proximal type 1 endoleak as a result of progressive neck dilatation after endovascular aneurysm repair is reported. A 74-year-old man with multiple comorbidities including severe ischemic heart disease, congestive cardiac failure, and chronic renal failure presented with a ruptured abdominal aortic aneurysm. He had an infrarenal endovascular aneurysm repair performed in 1999 and had subsequently developed a proximal type 1 endoleak. At open laparotomy, the placement of 4 nylon ties around the infrarenal aneurysm neck to refashion a seal and exclude the sac from systemic pressurization effectively treated the rupture. In the high-risk patient, ruptured proximal type 1 endoleak can be successfully treated with external banding avoiding the potential morbidity seen with the aortic clamping and blood loss of open conversion.