Changes in blood pressure and heart rate during sedation with ketamine in the pediatric ED.

BACKGROUND: Ketamine is commonly used in the emergency department for short, painful procedures. We describe changes in blood pressure (BP) and heart rate (HR) during procedural sedation with ketamine, as these changes have not been well described in children. METHODS: We performed a secondary analysis of a prospective, observational study involving children aged 8 to 18 years who received procedural sedation with ketamine in a pediatric emergency department. Serial vital signs and sedation scores were recorded from baseline until recovery from ketamine procedural sedation. Time of orthopedic manipulation was also recorded. Linear mixed-effect models were used to evaluate changes in systolic BP (SBP), diastolic BP (DBP), and HR using 3 sedation strata: presedation (baseline), sedated (ketamine administered and patient deeply sedated), and recovery (ketamine administered with patient minimally sedated), controlling for age and weight. RESULTS: Sixty children were enrolled; 10 were excluded due to missing manipulation time. A total of 394 observations were recorded. Mean sedated SBP, DBP, and HR were 8 mm Hg, 4 mm Hg, and 13 beats/min higher than presedation SBP (P<.001), DBP (P<.01), and HR (P<.001), respectively. Mean sedated SBP and DBP were 3 and 4 mm Hg higher than SBP (P=.006) and DBP (P<.01) during recovery. Manipulation increased mean SBP by 5 mm Hg (P<.001), mean DBP by 7 mm Hg (P<.001), and mean HR by 1 beat/min (P=.35). CONCLUSIONS: Ketamine administered during procedural sedation for painful procedures causes a statistically significant but modest increase in SBP, DBP, and HR. Orthopedic manipulation further increases BP.

Pediatric Surfer's Myelopathy.

BACKGROUND: We present the case of the youngest known patient diagnosed with surfer's myelopathy. Surfer's myelopathy is a rare nontraumatic myelopathy. The most likely etiology, presumably, is arterial insufficiency related to spine hyperextension. Symptoms consist of back pain, urinary incontinence or retention, paraplegia, and sensory loss. CASE REPORT: A 7-year-old girl presented with back pain, urinary retention, and lower extremity weakness after doing backbends during a cheerleading practice the day prior to presentation. WHY SHOULD AN EMERGENCY MEDICINE PHYSICIAN BE AWARE OF THIS?: With the trend of children becoming increasingly active in competitive sports at a younger age, surfer's myelopathy is a diagnosis that should be considered when the symptoms are present and the history consists of hyperextending the back. As in our case, a seemingly benign trauma can lead to the diagnosis of surfer's myelopathy.

Ketamine and intraocular pressure in children.

STUDY OBJECTIVE: We determine the increase in intraocular pressure during pediatric procedural sedation with ketamine, and the proportion of children whose increase might be clinically important (at least 5 mm Hg). METHODS: We prospectively enrolled children aged 8 to 18 years, chosen to receive ketamine sedation in a pediatric emergency department. We measured intraocular pressure before sedation, immediately after ketamine administration, 2 minutes post-drug administration, and every 5 minutes thereafter until recovery or 30 minutes after the final dose. We descriptively report our observations. RESULTS: For the 60 children enrolled, the median intraocular pressure increase was 3 mm Hg (range 0 to 8 mm Hg). Fifteen children had a brief greater than or equal to 5 mm Hg increase in intraocular pressure from baseline. CONCLUSION: In this study of ketamine sedation in children with healthy eyes, we observed mild increases in intraocular pressure that at times transiently exceeded our bounds for potential clinical importance (5 mm Hg).

Hot asphalt burns: a review of injuries and management options.

Hot asphalt burns to human tissue can increase the likelihood of infection and potential conversion of partial thickness to full-thickness injuries. Successful intervention for hot asphalt burns requires immediate and effective cooling of the asphalt on the tissue followed by subsequent gradual removal of the cooled asphalt. A review of the literature reveals that multiple substances have been used to remove asphalt, including topical antibiotics, petroleum jelly, a commercial product known as De-Solv-It (ORANGE-SOL, Chandler, AZ), sunflower oil, baby oil, liquid paraffin, butter, mayonnaise, and moist-exposed burn ointment (MEBO). Although many of these products may be effective in the removal of asphalt, they may not be readily available in an emergency department setting. Topical antibiotics are readily available, are more commonly described in the medical literature, and would be expected to be effective in the removal of asphalt. We developed guidelines for on scene (first-aid) management and the initial care of such patients upon presentation to a health care facility. These guidelines emphasize the principles of early cooling, gradual removal of adherent asphalt using topical antibiotics, and avoidance of the use of topical agents, which are likely to result in tissue toxicity.