Aim: To examine the effectiveness and safety of the sedative agents used in the emergency department following the introduction of ketamine as an agent for procedural sedation Methods: A 2-year prospective audit of sedation practice was undertaken. This specifically examined the rationale behind a doctor's choice of sedative agent, the depth of sedation achieved, adverse events and the time taken to regain full orientation. Results: 210 patients were included of whom 85 (40%) were given ketamine, 107 (51%) midazolam and 18 (9%) propofol. The median time to full orientation was 25 min for ketamine, 30 min for midazolam and 10 min for propofol. Complications occurred in 15.9% of sedations overall (14.6% of those given ketamine, 15.8% given midazolam and 22.2% given propofol). Apnoea and hypoxia most often occurred with midazolam and propofol, while hypertension and hypertonicity were encountered more frequently with ketamine. In addition, 19.5% of patients given ketamine suffered the reemergence phenomenon. The association between deep sedation with no response to pain and adverse events encountered with midazolam does not occur with ketamine. Conclusions: Ketamine is both safe and effective and compares favourably with midazolam as an agent for procedural sedation in the emergency department. Although the re-emergence phenomenon occurred, no psychological sequelae were encountered after return to full orientation. Ketamine may be particularly useful in groups of patients at high risk of adverse effects with midazolam.Ketamine produces a dissociative state and provides good analgesia at a subanaesthetic dosage.

ObjectivesAlcohol is responsible for a proportion of emergency admissions to hospital, with acute alcohol intoxication and chronic alcohol dependency (CAD) implicated. This study aims to quantify the proportion of hospital admissions through our emergency department (ED) which were thought by the admitting doctor to be (largely or partially) a result of alcohol consumption.SettingED of a UK tertiary referral hospital.ParticipantsAll ED admissions occurring over 14 weeks from 1 September to 8 December 2012. Data obtained for 5497 of 5746 admissions (95.67%).Primary outcome measuresProportion of emergency admissions related to alcohol as defined by the admitting ED clinician.Secondary outcome measuresProportion of emergency admissions due to alcohol diagnosed with acute alcohol intoxication or CAD according to ICD-10 criteria.Results1152 (21.0%, 95% CI 19.9% to 22.0%) of emergency admissions were thought to be due to alcohol. 74.6% of patients admitted due to alcohol had CAD, and significantly greater than the 26.4% with ‘Severe’ or ‘Very Severe’ acute alcohol intoxication (p<0.001). Admissions due to alcohol differed to admissions not due to alcohol being on average younger (45 vs 56 years, p<0.001) more often male (73.4% vs 45.1% males, p<0.001) and more likely to have a diagnosis synonymous with alcohol or related to recreational drug use, pancreatitis, deliberate self-harm, head injury, gastritis, suicidal ideation, upper gastrointestinal bleeds or seizures (p<0.001). An increase in admissions due to alcohol on Saturdays reflects a surge in admissions with acute alcohol intoxication above the weekly average (p=0.003).ConclusionsAlcohol was thought to be implicated in 21% of emergency admissions in this cohort. CAD is responsible for a significantly greater proportion of admissions due to alcohol than acute intoxication. Interventions designed to reduce alcohol-related admissions must incorporate measures to tackle CAD.

Trekkers who indicated that they would act safely in the event of developing moderate to severe AMS were significantly less likely to be suffering from AMS when interviewed and had ascended significantly less altitude in the preceding 72 h being more likely to adhere to recommended ascent guidelines.

The majority of ambulances were called appropriately; however, there remains a significant proportion who could travel by other means. A high proportion of ambulance arrivals between midnight and 05:00 hours were intoxicated, abusive or victims of assault. This supported staff's perception that such patients form a substantial proportion of departmental workload at night.

We hypothesise that the infection was introduced from the community on several occasions and was subsequently passed among staff within the department. Infection control measures designed for the inpatient setting can be partially applied to the emergency department. We felt the most useful measures would be early identification and isolation of infectious patients, barrier nursing, escalation of cleaning of the department and early investment in replacement staff to allow ill staff members to remain isolated at home and to prevent understaffing.