ABSTRACT
OBJECTIVE: To compare the efficacy of oral ketamine (10 mg/kg) with oral midazolam (0.7 mg/kg) in providing sedation for suturing of lacerations. METHOD: Prospective, randomised, double blinded trial with consecutive, concealed recruitment of 59 children aged 1 to 7 with wounds requiring local anaesthetic (LA) injection or topical LA with an anxiety score greater than one. RESULTS: Tolerance to LA injection was better with ketamine (p=0.029) and tolerance to procedure after LA injection showed a trend towards being improved with ketamine (p=0.067). There was no difference in tolerance to LA application or procedure in children receiving topical LA. Time to reach a sedation score of less than four was faster with ketamine (medians 20 versus 43 minutes, p=0.001) but times from dosing to discharge (medians 105 and 110 minutes) were similar. Inconsolable agitation was reported with midazolam in six cases. Dysphoria was not noted with ketamine. Vomiting was more common with ketamine but not significantly so (six versus two, p = 0.14). Oxygen desaturations were noted in both groups. Ataxia after discharge was seen in four patients, two in each group. Thirty six per cent of children showed new behavioural disturbances in the two weeks after discharge, more commonly in the midazolam group (p=0.048). CONCLUSIONS: At these doses tolerance to LA injection was better in children receiving ketamine, with fewer behavioural changes noted in the first two weeks. Midazolam at this dose caused dysphoric reactions, which may have affected the results. Continuous pulse oximetry monitoring is required when using these drugs. Vomiting and prolonged ataxia occurred in a few patients.
Subject(s)
Conscious Sedation , Ketamine/administration & dosage , Midazolam/administration & dosage , Wounds and Injuries/surgery , Administration, Oral , Anxiety/diagnosis , Anxiety/drug therapy , Child , Child, Preschool , Dose-Response Relationship, Drug , Emergency Service, Hospital , Female , Humans , Infant , Ketamine/adverse effects , Male , Midazolam/adverse effects , SuturesABSTRACT
BACKGROUND: Comparison of trauma survival rates between institutions and reference data bases is hampered by different injury severity mixes. To overcome this, a standardized comparison using a stratified W statistic (Ws) has been proposed. Ws enables comparisons but does not represent actual survival rates at an institution. METHOD, DISCUSSION, AND RESULTS: This discussion paper uses, as an example, data from 632 patients with blunt injuries treated by an integrated trauma system comprising a helicopter emergency medical service and the Royal London Hospital. Using the United Kingdom Major Trauma Outcome Study as a reference data set, Ws is calculated and its usefulness discussed. The problem of overprediction of survival is discussed. A modification of the Ws method is used to allow for this and to estimate the actual survival rate. CONCLUSION: Ws is useful for comparison between centers. Trauma and Injury Severity Score methodology overpredicts survival in certain probability of survival intervals. Adjustment can be made to estimate the actual survival rate. When applied to an integrated trauma system, such adjustments demonstrate overall improved survival, most noticeable in a more severely injured subgroup.
Subject(s)
Trauma Centers/statistics & numerical data , Trauma Severity Indices , Wounds and Injuries/classification , Wounds and Injuries/mortality , Diagnosis-Related Groups , Emergency Medical Services/organization & administration , Emergency Medical Services/statistics & numerical data , Humans , Injury Severity Score , London , Outcome Assessment, Health Care , Predictive Value of Tests , Survival Rate , Wounds and Injuries/epidemiologyABSTRACT
The case is described of a man who feigned being struck by a vehicle, leading to an unnecessary major trauma response by the ambulance service and hospital. Suspicion that the patient suffered from Munchausen syndrome was confirmed by later investigation. Accident and emergency staff should file details of such patients on the department computer records system, where available, so that staff are alerted automatically to their presence, and share this information with neighbouring hospitals. All such patients should be treated according to ATLS guidelines until injury is ruled out, as for any other patient.
Subject(s)
Munchausen Syndrome , Accidents, Traffic , Adult , Emergency Service, Hospital , Humans , Male , Medical Records Systems, ComputerizedABSTRACT
When Harvey Cushing described his syndrome in 1932 he named it the killing disease because of its cardiovascular complications. Heart failure is rarely reported as a presenting feature. We report a case in which left ventricular failure (LVF) was the predominant feature, associated with gross left ventricular hypertrophy (LVH) which regressed after treatment.
