Fixed dose ketamine for prehospital management of hyperactive delirium with severe agitation.

INTRODUCTION: Patients exhibiting signs of hyperactive delirium with severe agitation (HDSA) may require sedating medications for stabilization and safe transport to the hospital. Determining the patient's weight and calculating the correct weight-based dose may be challenging in an emergency. A fixed dose ketamine protocol is an alternative to the traditional weight-based administration, which may also reduce dosing errors. The objective of this study was to evaluate the frequency and characteristics of adverse events following pre-hospital ketamine administration for HDSA. METHODS: Emergency Medical Services (EMS) records from four agencies were searched for prehospital ketamine administration. Cases were included if a 250 mg dose of ketamine was administered on standing order to an adult patient for clinical signs consistent with HDSA. Protocols allowed for a second 250 mg dose of ketamine if the first dose was not effective. Both the 250 mg initial dose and the total prehospital dose were analyzed for weight based dosing and adverse events. RESULTS: Review of 132 cases revealed 60 cases that met inclusion criteria. Patients' median weight was 80 kg (range: 50-176 kg). No patients were intubated by EMS, one only requiring suction, three required respiratory support via bag valve mask (BVM). Six (10%) patients were intubated in the emergency department (ED) including the three (5%) supported by EMS via BVM, three (5%) others who were sedated further in the ED prior to requiring intubation. All six patients who were intubated were discharged from the hospital with a Cerebral Performance Category (CPC) 1 score. The weight-based dosing equivalent for the 250 mg initial dose (OR: 2.62, CI: 0.67-10.22) and the total prehospital dose, inclusive of the 12 patients that were administered a second dose, (OR: 0.74, CI: 0.27, 2.03), were not associated with the need for intubation. CONCLUSION: The 250 mg fixed dose of ketamine was not >5 mg/kg weight-based dose equivalent for all patients in this study. Although a second 250 mg dose of ketamine was permitted under standing orders, only 12 (20%) of the patients were administered a second dose, none experienced an adverse event. This indicates that the 250 mg initial dose was effective for 80% of the patients. Four patients with prehospital adverse events likely related to the administration of ketamine were found. One required suction, three (5%) requiring BVM respiratory support by EMS were subsequently intubated upon arrival in the ED. All 60 patients were discharged from the hospital alive. Further research is needed to determine an optimal single administration dose for ketamine in patients exhibiting signs of HDSA, if employing a standardized fixed dose medication protocol streamlines administration, and if the fixed dose medication reduces the occurrence of dosage errors.

Relationship between Physical Activity and Pain in U.S. Adults.

PURPOSE: We sought to assess the relationship between physical activity (PA) and pain within the available sample, with secondary aims to assess prevalence of pain, PA levels, health care seeking behaviors, and impact of pain on daily activities and work. METHODS: We conducted an epidemiological cross-sectional observational study utilizing National Health Interview Survey data from 2020. We examined the self-reported adherence to current PA guidelines and the prevalence of pain. We hypothesized those dealing with pain were less likely to meet PA guidelines. The PA levels, pain prevalence, frequency, and intensity were assessed via the survey and relationships explored via modeling. RESULTS: Of 31,568, 46% were men and 53.99% women with mean age of 52.27 yr (±17.31 yr). There were 12,429 (39.37%) participants that reported pain on some days, 2761 (8.75%) on most days, and 4661 (14.76%) every day. The odds of engaging in PA decreased in a stepwise fashion based on frequency and intensity of pain reporting when compared with no pain. Importantly, PA is a significant correlate affecting pain reporting, with individuals engaging in PA (strength and aerobic) demonstrating two times lower odds of reporting pain when compared with those not meeting the PA guidelines. CONCLUSIONS: There is a significant correlation between meeting PA guidelines and pain. Meeting both criteria of PA guidelines resulted in lower odds of reporting pain. In addition, the odds of participating in PA decreased based on pain frequency reporting. These are important findings for clinicians, highlighting the need for assessing PA not only for those dealing with pain but also as a potential risk factor for minimizing development of chronic pain.

An exploration of low back pain beliefs in a Northern America based general population.

BACKGROUND: Prior research has demonstrated that people across different populations hold beliefs about low back pain (LBP) that are inconsistent with current evidence. Qualitative research is needed to explore current LBP beliefs in Northern America (NA). OBJECTIVES: We conducted a primarily qualitative cross-sectional online survey to assess LBP beliefs in a NA population (USA and Canada). METHODS: Participants were recruited online using social media advertisements targeting individuals in NA over the age of 18 with English speaking and reading comprehension. Participants answered questions regarding the cause of LBP, reasons for reoccurrence or persistence of LBP, and sources of these beliefs. Responses were analyzed using conventional (inductive) content analysis. RESULTS/FINDINGS: 62 participants were included with a mean age of 47.6 years. Most participants reported multiple causes for LBP as well as its persistence and reoccurrence, however, these were biomedically focused with minimal to no regard for psychological or environmental influences. The primary cited source of participants' beliefs was healthcare professionals. CONCLUSIONS: Our findings align with prior research from other regions, demonstrating a need for updating clinical education and public messaging about the biopsychosocial nature of LBP.

Emergency Department Patients' COVID-19 Vaccination Status and Self-Reported Barriers.

INTRODUCTION: This study surveyed adult emergency department (ED) patients and the adult companions of pediatric patients to determine whether rates of coronavirus disease 2019 (COVID-19) vaccination were comparable to that of the general population in the region. This study also sought to identify self-reported barriers to vaccination and possible areas for intervention. METHODS: A survey was administered to 607 adult ED patients or the adult companions of pediatric patients from three different regional hospitals to assess their COVID-19 vaccination status, COVID-19 vaccine barriers, and demographic information. RESULTS: Of the 2,267 adult patients/companions considered for enrollment, we approached 730 individuals about participating in the study. Of the individuals approached, 607 (41% male; mean age 47.0+17.4 years) consented to participate. A total of 403 (66.4%) participants had received at least one vaccine dose as compared to 70% of the adult population in the county where the three hospitals were located. Of those, 382 (94.8%) were fully vaccinated and among the individuals who were partially vaccinated the majority (17 of 21) had an appointment for their second dose. Of those approached, 204 (33.6%) were not vaccinated, with 66 (10.9% of the total population) expressing an interest in becoming vaccinated while the remaining 138 did not want to be vaccinated. Of those who wanted to be vaccinated 32% were waiting for more safety data, and of those who did not want to be vaccinated 26% were concerned about side effects and risks and 28% were waiting for more safety data. CONCLUSION: Adult ED patients and adult companions of pediatric ED patients were vaccinated at a slightly lower rate than the general population in our county. A small but significant proportion of those who were unvaccinated expressed the desire to be vaccinated, indicating that the ED may be a suitable location to introduce a COVID-19 vaccination program.

Electromyographical Assessments of Recommended Neck and Trunk Positions for Dental Hygienists.

Purpose: Dental professionals are recommended to limit neck and trunk flexion to within 20° of a neutral (0°) body posture, however empirical support for the recommendations is lacking. The purpose of this study was to determine whether there are differences in muscle workload between a range of neck and trunk postures in a population of dental hygiene students.Methods: Fifteen first semester senior dental hygiene students with no history of neck and trunk injury volunteered to participate. Surface electromyography was used to record muscle activity from two neck extensors muscles, cervical erector spinae (CES) and upper trapezius (UT), and two trunk extensor muscles, thoracic erector spinae (TES) and iliocostalis lumboruni (IL). Participants performed ten conditions, including five neck flexion angles (0°, 10°, 20°, 30°, 40°) and five trunk flexion angles (0°,10°, 20°, 30°, 40°). For each trial, posture was checked with a goniometer and maintained for 20s. Muscle activity for each muscle was normalized to the individual's maximum voluntary isometric contraction (MVIC).Results: Activity of the CES was significantly lower in the neutral position than all flexed neck positions. Activation of the UT increased with neck flexion but required 30° of flexion to differ significantly from the neutral position. Activity of the TES required 20° of trunk flexion to differ significantly from neutral and IL activity in the neutral position was significantly lower than all other trunk flexion conditions.Conclusion: Even small amounts of neck or trunk flexion (10°), within the recommended range (≤ 20°), can significantly increase the workload for some muscles in an oral health care provider.

Bracing the trunk and neck in young adults leads to a more aged-like gait.

Older individuals typically walk at slower speeds, with shorter step lengths, greater step widths and spend a larger proportion of the gait cycle in double stance. Changes in neck and trunk mobility may underlie some of the changes in walking seen with increasing age. Consequently, this study was designed to assess whether externally increasing trunk/neck stiffness in young adults leads to similar changes in gait pattern observed with aging. Twelve young adults (20-29 years), sixteen old adults (60-69 years) and fifteen older adults (70-79 years) walked across a 20' pressure sensitive GAITRite© instrumented walkway at their preferred speed. The young adults also walked under three bracing conditions: (1) Neck braced, (2) Trunk braced, and (3) Neck and Trunk braced. The results revealed that the old and older age groups walked significantly slower, with a shorter step length and with a narrower base of support (p's<0.05) compared to the young adults. In young adults, combined neck and trunk bracing led to reduced walking speed, shorter step length, wider base of support and a larger proportion of the gait cycle spent in double stance (p's<0.05). The walking speed and step length of older adults remained less than fully braced young adults (p's<0.05). Overall these results indicate that artificially stiffening the trunk and neck of young individuals leads to systematic gait changes similar to aging. Consequently, age-related changes in mobility of the neck and torso may in part contribute to the decrements in walking seen for older adults.

Impact Forces of Walking and Running at the Same Intensity.

Moderate-intensity walking (horizontal, WH), vigorous-intensity walking (incline, WI), and vigorous-intensity running (horizontal, R) were compared. The hypothesis is that running creates greater loading forces than walking even at the same aerobic intensity. Young adults (10 M and 10 F; age, 22.8 ± 0.5 years) performed 3 exercise trials in a counter-balanced order: walking 5.5 kph at 0% grade (WH); walking 5.5 kph at 11% (WI); and running at 8.0 kph at 0% (R). Oxygen consumption (V[Combining Dot Above]O2), step frequency, peak vertical ground reaction force (VGRF), and vertical force loading rate were recorded during the last 5 minutes of each trial. Results are mean ± SE. Net V[Combining Dot Above]O2 during WH (10.5 ± 0.3 ml·min·kg) was significantly less than WI (26.3 ± 0.3) and R (25.1 ± 0.7 ml·min·kg). Step frequency was significantly greater during R (163 ± 1.5 steps per minute) than both walking conditions (WH, 128 ± 1.0 steps per minute; WI, 126 ± 1.2 steps per minute). Peak VGRF was significantly greater during running (844 ± 47 N) than both walking conditions (WH, 581 ± 27 N; WI, 565 ± 28 N). Force loading rate was significantly greater with R (8,214 ± 26 N·s) than WH (6,497 ± 15 N·s ) and WI (5,699 ± 16 N·s ), with WH > WI. Vigorous-intensity walking produced no greater loading forces than moderate-intensity walking. However, running at a vigorous intensity produced substantially greater loading forces than walking of the same intensity. These findings suggest that vigorous aerobic exercise may be performed without elevated orthopedic stress, depending on the mode prescribed.

High-intensity tasks with external load in military applications: a review.

This article provides a synopsis of the limited investigations examining the impact of external load (EL) on performance of high-intensity tasks under load (HITL), EL training intervention effects on HITL performance, and injuries from EL training. Repetitive lifting tasks and initiation of locomotion, such as rapidly moving from a prone position to sprinting appear to be more hindered by EL than maximal sprinting velocity and may explain why training with EL does not improve obstacle course or prolonged (200-300 yard shuttle) drills. EL training appears to offer very little if any benefit for HITL in lesser trained populations. This contrast results of multiple studies incorporating ≥ 3 weeks of prolonged hypergravity interventions (wearing EL during daily activities) in elite anaerobic athletes, indicating EL training stimulus is likely only beneficial to well-trained soldiers. Women and lesser trained individuals appear to be more susceptible to increased injury with EL training. A significant limitation concerning current HITL knowledge is the lack of studies incorporating trained soldiers. Future investigations concerning the effects of HITL on marksmanship, repetitive lifting biomechanics, efficacy of hypergravity training for military personnel, and kinematics of sprinting from tactical positions with various EL displacements and technique training are warranted.