ObjectivesTraumatic brain injury (TBI) is commonly seen in the emergency department (ED). Approximately 85%–90% of TBIs are mild (mTBI). Some cause symptoms such as headache, dizziness, anxiety, blurred vision, insomnia and concentration difficulties, collectively known as postconcussion syndrome (PCS). Some studies suggest that recovery from mTBI is complete. Others find that symptoms persist for months, even years. The aim of this study was to describe the use of general practice, before and after mTBI, as a proxy for symptoms in a large cohort.DesignNationwide population-based matched cohort study.SettingDanish EDs and general practice.ParticipantsAll patients (aged ≥18 years), first-time diagnosed with mTBI in a Danish ED between 1 January 1998 and 31 December 2010 (n=93 517). Ten reference persons per patient with mTBI were randomly matched on gender, age and general practice (n=935 170).Primary outcomeOverall use of general practice; consultations relating to mental and physical health.ResultsWe found higher use of general practice during the first year after mTBI for all ages, both genders and all types of contacts. Age 18–40 years: women, incidence rate ratio (IRR) 1.59 (95% CI 1.57 to 1.61); men, IRR 1.82 (95% CI 1.80 to 1.85). Age 41–65 years: women, IRR 1.75 (95% CI 1.72 to 1.78); men, IRR 1.85(95% CI 1.82 to 1.89). Age 66+ years: women, IRR 1.55 (95% CI 1.52 to 1.58); men, IRR 1.55 (95% CI 1.51 to 1.59). After the first year, the use decreased to the level before mTBI. Individuals with mTBI and higher use of general practice before mTBI had lower socioeconomic status and more comorbidities (P<0.001).ConclusionsThe use of general practice was higher in the first year after mTBI, specifically in the first 3 months. Patients with mTBI had different healthcare-seeking behaviour several years before diagnosis than their matched reference persons. Pretraumatic morbidity should be considered in the evaluation of PCS.

ObjectiveTo evaluate the effectiveness of a subanaesthetic single-dose ketamine (SDK) as an adjunct to opioids for acute pain in emergency department (ED) settings.DesignSystematic review and meta-analysis.MethodsA systematic search was performed in MEDLINE, Embase, Scopus and Web of Science through March 2022. Randomised controlled trials (RCTs) that investigated SDK as an adjunct to opioids in adult patients for any painful condition in ED settings were selected. Two reviewers screened studies, extracted data and assessed study quality. Data were pooled using random-effects models. The primary outcome was mean pain intensity score measured at baseline, >0–15 min, >15–30 min, >30–45 min, 60 min, 90 min and 120 min. Secondary outcomes included need for rescue analgesia, adverse events and patient satisfaction. Results were reported as mean differences (MDs) and risk ratios. Statistical heterogeneity was calculated using theI2statistic.ResultsEight RCTs were included (n=903). Studies were judged to be at moderate to high risk of bias. Mean pain intensity scores were significantly lower 60 min after study drug administration favouring adjuvant SDK (MD −0.76; 95% CI −1.19 to −0.33), compared with opioids alone. There was no evidence of differences in mean pain intensity scores at any other time point. Patients who received adjuvant SDK were less likely to require rescue analgesia, no more likely to experience serious side effects and had higher satisfaction scores, compared with opioids alone.ConclusionsAvailable evidence suggests adjuvant SDK can have an effect on lowering pain intensity scores. Although reduction of pain scores was not clinically significant, the combination of reduced pain intensity and reduced opioid requirements suggest the results could be clinically important and support the potential utility of SDK as an adjunct to opioids to treat acute pain in adult ED patients. However, current evidence is limited and higher quality RCTs are needed.PROSPERO registration numberCRD42021276708.

Background: Seventy percent of the yearly 1.8 million emergency contacts to the Danish hospitals arrives from patients in pain. Pain management is an essential and challenging part of emergency medicine and ineffective analgesia for patients attending the emergency department (ED) is common and can lead to complications, extended hospital stays and course of illness. Opioid-tolerant patients are an increasing challenge requiring different acute pain management, ie. needing much larger doses of opioids – which for a number of reasons they do not receive.  The rising need for opioid sparing treatment and the difficulties in pain treatment of patients with a current use of opioids calls for clinical studies investigating effect and safety of alternatives. Low-Dose-Ketamine (LDK) has been studied as an analgesic and been shown to be useful in the reduction of acute pain in the postoperative setting. This study will evaluate the efficacy and safety of LDK as an adjunct to morphine in the treatment of pain in the ED. Hypothesis: LDK as an adjunct to morphine will be superior to morphine alone as regards of analgesic effect. The combination of morphine and LDK will result in a larger pain reduction in patients with a current use of opioids than patients with no prior use. Methods: Randomized, double-blinded trial, investigating the combination of LDK and morphine versus IV morphine alone regarding analgesic effect.  152 patients fulfilling all inclusion criteria and no exclusion criteria will be stratified (prior use of opioids and no prior use of opioids) and randomized in a 1:1 ratio in the two groups. Perspectives:  This is the first study to examine the effect of LDK as an adjunct to morphine in a general patient population in the ED with pain and to compare it with the effect for patients with a prior use of opioids. This study could present a better pain treatment for patients with and without a prior use of opioids. Results: Pending – study still running. Conclusion: Pending – study still running.

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