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Objectives: The authors sought to compare the safety and efficacy of subdissociative-dose ketamine versus fentanyl as adjunct analgesics for emergency department (ED) procedural sedation and analgesia (PSA) with propofol.Methods: This double-blind, randomized trial enrolled American Society of Anesthesiology (ASA) Class I or II ED patients, aged 14-65 years, requiring PSA for orthopedic reduction or abscess drainage. Subjects received 0.3 mg ⁄ kg ketamine or 1.5 lg ⁄ kg fentanyl intravenously (IV), followed by IV propofol titrated to deep sedation. Supplemental oxygen was not routinely administered. The primary outcomes were the frequency and severity of cardiorespiratory events and interventions, rated using a composite intrasedation event rating scale. Secondary outcomes included the frequency of specific scale component events, propofol doses required to achieve and maintain sedation, times to sedation and recovery, and physician and patient satisfaction.Results: Sixty-three patients were enrolled. Of patients who received fentanyl, 26 ⁄ 31 (83.9%) had an intrasedation event versus 15 ⁄ 32 (46.9%) of those who received ketamine. Events prospectively rated as moderate or severe were seen in 16 ⁄ 31 (51.6%) of fentanyl subjects versus 7 ⁄ 32 (21.9%) of ketamine subjects. Patients receiving fentanyl had 5.1 (95% confidence interval [CI] = 1.9 to 13.6; p < 0.001) times the odds of having a more serious intrasedation event rating than patients receiving ketamine. There were no significant differences in secondary outcomes, apart from higher propofol doses in the ketamine arm.Conclusions: Subdissociative-dose ketamine is safer than fentanyl for ED PSA with propofol and appears to have similar efficacy.ACADEMIC EMERGENCY MEDICINE 2008; 15:877-886 ª

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Objective:To determine if peripheral venous blood gas values for pH, partial pressure of carbon dioxide (PCO2) and the resultant calculated bicarbonate (HCO3) predict arterial values accurately enough to replace them in a clinical setting.Methods:This prospective observational study was performed in a university tertiary care emergency department from June to December 1998. Patients requiring arterial blood gas analysis were enrolled and underwent simultaneous venous blood gas sampling. The following data were prospectively recorded: age, sex, presenting complaint, vital signs, oxygen saturation, sample times, number of attempts and indication for testing. Correlation coefficients and mean differences with 95% confidence intervals (CIs) were calculated for pH,PCO2and HCO3. A survey of 45 academic emergency physicians was performed to determine the minimal clinically important difference for each variable.Results:The 218 subjects ranged in age from 15 to 90 (mean 60.4) years. The 2 blood samples were drawn within 10 minutes of each other for 205 (96%) of the 214 patients for whom data on timing were available. Pearson’s product–moment correlation coefficients between arterial and venous values were as follows: pH, 0.913;PCO2, 0.921; and HCO3, 0.953. The mean differences (and 95% CIs) between arterial and venous samples were as follows: pH, 0.036 (0.030–0.042);PCO2, 6.0 (5.0–7.0) mm Hg; and HCO3, 1.5 (1.3–1.7) mEq/L. The mean differences (± 2 standard deviations) were greater than the minimum clinically important differences identified in the survey.Conclusions:Arterial and venous blood gas samples were strongly correlated, and there were only small differences between them. A survey of emergency physicians suggested that the differences are too large to allow for interchangeability of results; however, venous values may be valid if used in conjunction with a correction factor or for trending purposes.

While substantial proportions of the population of Ontario, Canada continue to have teeth extracted, little is known about the reasons for this loss. In this survey of Ontario general dental practitioners, 128 dentists provided information on 6143 patients they saw during a reference week. Approximately one-in-seven of these patients had or were going to have one or more extractions as part of their current course of treatment. The mean number of extractions for patients having at least one tooth taken out was 2.3 (SD = 2.5). Emergency patients were more likely than regular patients to have at least one extraction but, on average, had fewer teeth taken out. Orthodontic considerations were the main reason for tooth loss in childhood, caries continued to be an important cause of tooth loss at all ages and periodontal disease accounted for more teeth lost after 40 years of age than caries. This study differs from almost all others in finding that, overall, more permanent teeth were extracted because of periodontal disease than because of caries. The former accounted for 35.9% of teeth lost and the latter for 28.9%. While this may be due to methodological differences between this and other studies, it is consistent with epidemiological data on periodontal disease in the Ontario population and data showing that Ontarians receive little in the way of periodontal care.