Abstract. Objective:To describe the clinical characteristics of a combination of midazolam and ketamine for procedural sedation and analgesia in adult emergency department (ED) patients. Methods: This was a prospective, observational trial, conducted in the ED of an urban level II trauma center. Patients Ն 18 years of age requiring procedural sedation and analgesia were eligible, and enrolled patients received 0.07 mg/kg of intravenous midazolam followed by 2 mg/kg of intravenous ketamine. Vital signs were recorded at regular intervals. The adequacy of sedation, adverse effects, patient satisfaction, and time to reach discharge alertness were determined. Descriptive statistics were calculated using statistical analysis software. Results: Seventy-seven patients were enrolled. Three were excluded due to protocol violations, three due to lack of documentation, and one due to subcutaneous infiltration of ketamine, leaving 70 patients for analysis. The average age was 31 years, and 41 (59%) were female. Indications for procedural sedation and analgesia included abscess incision and drainage (66%), fracture/joint reduction (26%), and other (8%). The mean dose of midazolam was 5.6 Ϯ 1.4 mg and the mean dose of ketamine was 159 Ϯ 42 mg. The mean time to achieve discharge criteria was 64 Ϯ 24 minutes. Five patients experienced mild emergence reactions, but there were no episodes of hallucinations, delirium, or other serious emergence reactions. Eighteen (25%) patients recalled dreaming while sedated; twelve (17%) were described as pleasant, two (3%) unpleasant, three (4%) both pleasant and unpleasant, and one (1%) neither pleasant nor unpleasant. There were four (6%) cases of respiratory compromise, two (3%) episodes of emesis, and one (1%) case of myoclonia. All of these were transient and did not result in a change in the patient's disposition. Only one (1%) patient indicated that she was not satisfied with the sedation regimen. Conclusions: The combination of midazolam and ketamine provides effective procedural sedation and analgesia in adult ED patients, and appears to be safe.

Abstract.Objective: Prior studies addressing the incidence of acute myocardial infarction (AMI) in patients with cocaine-associated chest pain have found divergent results. Previous prospective studies, which found approximately a 6% incidence of AMI, have been criticized for selection bias. This study sought to determine the rate of AMI in patients with cocaineassociated chest pain. Methods: All patients seen in an urban university-affiliated hospital between July 1996 and February 1998 were identified by ICD-9 medical records search for cocaine use and chest pain/ acute coronary syndromes. In this system, all faculty admit all patients with cocaine-associated chest pain for at least 23-hour observation periods. Data collected included demographics, medical and cocaine use history, presenting characteristics, hospital course, cardiovascular complications, and diagnostic tests using a 119-item closed-question data instrument with high interrater reliability. The main outcome measure was AMI according to World Health Organization (WHO) criteria. Results: There were 250 patients identified with a mean age of 33.5 Ϯ 8.5 years; 77% were male; 84% were African American. Of 196 patients tested, 185 had cocaine or cocaine metabolites in the urine (94%). The incidence of cardiac risk factors were: hypercholesterolemia, 8%; diabetes, 6%; family history, 34%; hypertension, 26%; tobacco use, 77%; prior MI, 6%; and prior chest pain, 40%. Seventy-seven percent admitted to cocaine use in the preceding 24 hours: crack, 85%; IV, 2%; nasal, 6%. Twenty-five patients (10%) had electrocardiographic evidence of ischemia. A total of 15 patients experienced an AMI (6%; 95% CI = 4.1% to 8.9%) using WHO criteria. Complications were infrequent: bradydysrrhythmias, 0.4%; congestive heart failure, 0.4%; supraventricular tachycardia, 1.2%; sustained ventricular tachycardia, 0.8%. Conclusion: The incidence of AMI was 6% in patients with cocaine-associated chest pain. This result is identical to that found in prior prospective studies. Key words: cocaine; acute coronary syndrome; acute myocardial infarction; emergency department; electrocardiogram. ACADEMIC EMERGENCY MEDICINE 2000; 7: 873-877 C OCAINE use is associated with a 24-fold increased risk of myocardial infarction during the hour immediately after use.1 Acute myocardial infarction (AMI) due to cocaine occurs in patients with and without diseased coronary arteries.2-4 Although recent data suggest that cocaine-associated chest pain is infrequently ischemic in nature, 5 chest pain remains the most frequent cocaine-associated emergency department (ED) complaint. 6 Previous studies have found a widely divergent incidence of AMI in patients with cocaine-associated chest pain, largely due to selection bias. COCHPA (Cocaine Associated Chest Pain) trial was the largest multicenter study to prospectively evaluate the incidence of cocaine-associated myocardial infarction. 11 That study determined the prevalence to be 6%. 11The purpose of this study was to determine the frequency of AMI in patie...

ABSTRACT. Objective. To compare the additive effect of a helium-oxygen mixture (Heliox) or racemic epinephrine (RE) on croup scores (CSs) in children with moderate to severe croup treated with humidified oxygen and steroids.Design. A prospective, randomized, double-blind trial.Setting. Emergency department and pediatric intensive care unit of an urban level I trauma center.Participants. Randomly assigned, consecutive children ages 6 months to 3 years presenting with moderate to severe croup (CS: >5).Interventions. After cool humidified oxygen and 0.6 mg/kg of intramuscular dexamethasone, patients were randomized to receive either Heliox or RE. Vital signs, oxygen saturation, and CSs were recorded at regular intervals.Outcome/Analysis. Reductions in CSs were compared using repeated-measures analysis of variance.Results. Thirty-three patients were enrolled. Three were excluded because of protocol violations, and 1 was excluded because of lack of documentation, leaving 29 patients for final analysis. The average age was 24.2 months, 20 were male (68.8%). Both Heliox and RE were associated with improvement in CSs over time. There were no significant differences in mean CS, oxygen saturation, respiratory rate, or heart rate between groups at baseline or at the end of the treatment period.Conclusion. In patients with moderate to severe croup, the administration of Heliox resulted in similar improvements in CS compared with patients given RE. Pediatrics 2001;107(6). URL: http://www.pediatrics.org/ cgi/content/full/107/6/e96; helium-oxygen mixture, croup.ABBREVIATIONS. RE, racemic epinephrine; CS, croup score; ED, emergency department. L aryngotracheobronchitis, or croup, is a common respiratory illness in children. Most cases of croup are mild and require only supportive care with humidified oxygen. However, in moderate to severe cases, aggressive therapy may be necessary to avoid exhaustion and subsequent respiratory failure. Although steroids have gained widespread acceptance as a means of attenuating subglottic edema, racemic epinephrine (RE) has long been considered the mainstay of acute therapy for moderate to severe croup. 1 Helium is a biologically inert gas that possesses a very low specific gravity (density) and is one third the viscosity of air. 2 These properties result in a decreased resistance to airflow (lower Reynolds number), and suggest that a helium-oxygen mixture may be a useful adjunct to improve ventilation via enhanced laminar airflow in the face of moderate to severe croup. Recently, mixtures of helium and oxygen have been used successfully in the pediatric intensive care unit setting for treatment of both refractory viral and postextubation croup. [3][4][5] Although both Heliox (AGA Gas, Flint, MI) and RE have been independently shown to decrease the work of breathing and lower croup scores (CSs), 3,4,6 no study to date has compared these modalities in the management of moderate to severe croup. Therefore, the purpose of this study was to compare the relative effect of Heliox and RE on CSs in pe...