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Atomized intranasal midazolam is a common adjunct in pediatrics for procedural anxiolysis. There are no previous studies of validated anxiety scores with pharmacokinetic data to support optimal procedure timing.We describe the clinical and pharmacokinetic profile of atomized intranasal midazolam in children presenting for laceration repair.Children 11 months to 7 years of age and weighing26 kg received 0.4 mg/kg of atomized intranasal midazolam for simple laceration repair. Blood samples were obtained at 3 time points in each patient, and the data were fit with a 1-compartment model. Patient anxiety was rated with the Observational Scale of Behavioral Distress. Secondary outcomes included use of adjunctive medications, successful completion of procedure, and adverse events.Sixty-two subjects were enrolled, with a mean age of 3.3 years. The median time to peak midazolam concentration was 10.1 min (interquartile range 9.7-10.8 min), and the median time to the procedure was 26 min (interquartile range 21-34 min). There was a trend in higher Observational Scale of Behavioral Distress scores during the procedure. We observed a total of 2 adverse events, 1 episode of vomiting (1.6%) and 1 paradoxical reaction (1.6%). Procedural completion was successful in 97% of patients.Atomized intranasal midazolam is a safe and effective anxiolytic to facilitate laceration repair. The plasma concentration was90% of the maximum from 5 to 17 min, suggesting this as an ideal procedural timeframe after intranasal midazolam administration.

Background Among those aged 5 years or younger, foreign bodies are the fourth most common pediatric exposure reported to the American Association of Poison Control Centers. Although the majority of ingested foreign bodies pass through the gastrointestinal tract without complication, those that do not spontaneously pass can lead to a number of serious complications, such as gastrointestinal obstruction or perforation, which can be complicated by bleeding from aortoesophageal fistula, secondary mediastinitis, peritonitis, esophageal or gastrointestinal fistula formation, and abscesses. Case Report We present the case of a 10-month-old child who presented with new-onset focal seizure in the setting of multiple brain abscesses, ultimately found to be due to esophageal perforation from a retained, metallic esophageal foreign body. Why Should an Emergency Physician Be Aware of This? Foreign bodies that are retained for longer than 24 h after ingestion have been associated with a higher risk of complications because they are less likely to pass spontaneously through the gastrointestinal tract. Early identification and removal of foreign bodies is necessary to prevent subsequent complications. In patients who have a subacute history of cough, gagging, vomiting, and decreased oral intake with an otherwise unknown cause, foreign-body ingestion or aspiration should be considered. In addition, central nervous system abscess and infection should be considered in patients with concerns about previous foreign body ingestion or aspiration and who are newly presenting with fever, focal neurologic changes, and irritability.

Ketamine is a well-studied and safe medication used for procedural sedation in the pediatric emergency department (ED). However, in our ED and urgent care (UC), we had higher rates of respiratory events receiving intervention (REs) than has been reported nationally.A quality improvement (QI) project was initiated to address this problem with the following aim: during a 24-month period, we aimed to decrease REs during i.v. ketamine sedation from10% to6% in our network of EDs and UCs.Inclusion criteria included patients in our EDs and UCs who received i.v. ketamine for procedural sedation. We organized a multidisciplinary team to identify key drivers for the primary outcome (i.e., REs) and establish interventions. We based process measures on key interventions and utilized 2 Plan-Do-Study-Act (PDSA) cycles, which we evaluated with Shewhart P (provost) charts. Balancing measures included length of sedation, success of sedation, and length of stay.REs decreased from 11.4% to 4.9%; this rate was maintained for 12 months, starting 1 month after PDSA cycle 2 implementation. There was no difference in REs for length of stay, length of sedation, or success of sedation.Using QI methodology, we reduced and maintained rates of RE to6%. Due to the nature of the project, it is difficult to link one intervention to the reduction in REs; however, a significant shift occurred just after PDSA cycle 2 interventions. This project can give a guideline for interventions to improve the safety of pediatric ketamine sedations.

Background The co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. Objective Our objective was to compare adverse events between ketamine monotherapy (KM) and CoKP for procedural sedation and analgesia (PSA) in a pediatric emergency department (ED). Methods This was a prospective, randomized, single-blinded, controlled trial of KM vs. CoKP in patients between 3 and 21 years of age. The attending physician administered either ketamine 1 mg/kg i.v. or ketamine 0.5 mg/kg and propofol 0.5 mg/kg i.v. The physician could administer up to three additional doses of ketamine (0.5 mg/kg/dose) or ketamine/propofol (0.25 mg/kg/dose of each). Adverse events (e.g., respiratory events, cardiovascular events, unpleasant emergence reactions) were recorded. Secondary outcomes included efficacy, recovery time, and satisfaction scores. Results Ninety-six patients were randomized to KM and 87 patients were randomized to CoKP. There was no difference in adverse events or type of adverse event, except nausea was more common in the KM group. Efficacy of PSA was higher in the KM group (99%) compared to the CoKP group (90%). Median recovery time was the same. Satisfaction scores by providers, including nurses, were higher for KM, although parents were equally satisfied with both sedation regimens. Conclusions We found no significant differences in adverse events between the KM and CoKP groups. While CoKP is a reasonable choice for pediatric PSA, our study did not demonstrate an advantage of this combination over KM.

Changes in the manner in which medications can be delivered can have significant effects on the quality of care in the acute care setting.The objective of this study was to evaluate the change in three Institute of Medicine quality indicators (timeliness, safety, and effectiveness) in the pediatric emergency department (ED) after the introduction of the Mucosal Atomizer Device Nasal™ (MADn) for opioid analgesia.This was a retrospective review of patients receiving opioid analgesia for certain conditions over a 5-year period. We compared patients receiving intravenous opioid (IVO) to those receiving intranasal fentanyl (INF). Timeliness outcomes include time from medication order to administration, time from dose to discharge, overall time to analgesia, and ED length of stay. Effectiveness outcomes include change in pain score and frequency of repeat dosing. Safety outcomes were the frequency of reversal agent administration or a documented oxygen desaturation of 90%. Sensitivity analyses were performed to evaluate the effect of moderate sedation on all three outcomes.During the study period, 1702 patients received opioid analgesia, 744 before and 958 after MADn introduction, of whom, 233 (24%) received INF. After MADn introduction, patients receiving INF had a shorter time to discharge from dose (109 vs. 203 min; p 0.05) and shorter ED length of stay (168 vs. 267 min; p 0.05). There was no difference in pain score reduction; however, repeat dosing was less frequent for patients receiving INF (16% vs. 27%). There was no use of reversal medication and no difference in the frequency of oxygen desaturations. When patients undergoing moderate sedation were removed from the analysis, there was no difference in the direction of findings for all three outcomes.INF is associated with improved timeliness and equivalent effectiveness and safety when compared to IVO in the setting of the pediatric ED.

Although activated charcoal (AC) is commonly used after ingestions of cocaine, the ability of AC to bind with this drug is unknown. We studied binding of cocaine to AC in vitro. Cocaine adsorption to charcoal for AC:drug ratios of 1:1, 2.5:1, and 5:1 at pH 1.2 was 40%, 92%, and 99%, respectively; at pH 8.0, it was 78%, 98%, and 99%, respectively. All means were significantly different (P less than 0.05) versus the control (no AC) at each pH. At the AC:drug ratio of 1:1, there was also significantly greater adsorption of cocaine at pH 8.0 than at pH 1.2. This study shows that AC strongly adsorbs cocaine under both acidic and alkaline conditions.