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OBJECTIVES We wanted to estimate the frequency and describe the nature of emergency department (ED) procedural sedation restrictions in the State of California. METHODS We surveyed medical directors for all licensed EDs statewide regarding limitations on procedural sedation practice. Our primary outcome was the frequency of restrictions on procedural sedation, defined as an inability to administer moderate sedation, deep sedation, and typical ED sedative agents in accordance with American College of Emergency Physicians (ACEP) guidelines. Our secondary outcomes were the nature of these restrictions, who has imposed them, why they were imposed, and the perceived clinical impact. RESULTS We obtained responses from 211 (64%) of the 328 EDs. Ninety-one (43%) reported conditional or total limitations on their ability to administer one or more of the following: moderate sedation, deep sedation, propofol, ketamine, or etomidate. Thirty-nine (18%) reported total restriction of at least one of these-most frequently a prohibition of deep sedation (18%). Local anesthesia directors were the most frequently cited creators and enforcers of these restrictions. Some respondents reported that, due to these restrictions, they used less effective sedatives, they performed procedures without sedation when sedation would have been preferred, and they observed inadequate sedation and pain control. CONCLUSIONS In this statewide survey we found a substantial prevalence of practice limitations-mostly created by local anesthesia directors-that restrict the ability of emergency physicians to provide procedural sedation for their patients in accordance with ACEP guidelines. Deep sedation was prohibited in 18% of responding EDs. Our respondents describe adverse consequences to patient care.

We detail the limitations of the current paradigm of the sedation continuum - a tool ubiquitous to all sedation care settings and now a quarter century old. Definitions in this existing taxonomy are based on patient responsiveness to verbal and/or tactile stimuli, and the inherent subjectivity of this focus has both challenged the reliable assessment of adverse event risk and precluded clear delineation of sedation boundaries, e.g., what is the dividing line between moderate and deep sedation? We present the rationale to support a broadening of this sedation continuum precept to include an objective mechanism to predict the ongoing risk of serious adverse events, and then propose sequential steps for the development of such a restructured framework. This process, while ambitious, would yield a clear and consistent language to facilitate quality assurance, provide an objective framework for standardized sedationist training and credentialing, and permit inclusion into computerized decision-support algorithms to facilitate more precise sedative delivery. It is important to clearly delineate this goal now to permit design and initiation of the requisite research.

Objectives: Adjunctive anticholinergics are commonly administered during emergency department (ED) ketamine sedation in children under the presumption that drying oral secretions should decrease the likelihood of airway and respiratory adverse events. Pharmacologic considerations suggest that glycopyrrolate might exhibit a superior adverse effect profile to atropine. The authors contrasted the adverse events noted with use of each of these anticholinergics in a large multicenter observational database of ketamine sedations. Methods: This was a secondary analysis of an observational database of 8,282 ED ketamine sedations assembled from 32 prior series. The authors compared the relative incidence of six adverse events (airway and respiratory adverse events, laryngospasm, apnea, emesis, recovery agitation, and clinically important recovery agitation) between children who received coadministered atropine, glycopyrrolate, or no anticholinergic. Multivariable analysis using the specific anticholinergic as a covariate was performed, while controlling for other known predictors. Results: Atropine was associated with less vomiting (5.3%) than either glycopyrrolate (10.7%) or no anticholinergic (11.4%) in both unadjusted and multivariable analyses. Glycopyrrolate was associated with significantly more airway and respiratory adverse events (6.4%) than either atropine (3.3%) or no anticholinergic (3.0%) and similarly more clinically important recovery agitation (2.1% vs. 1.2 and 1.3%). There were, however, no differences noted in odds of laryngospasm and apnea. Conclusions: This secondary analysis unexpectedly found that the coadministered anticholinergic atropine exhibited a superior adverse event profile to glycopyrrolate during ketamine sedation. Any such advantage requires confirmation in a separate trial; however, our data cast doubt on the traditional premise that glycopyrrolate might be superior. Further, neither anticholinergic showed efficacy in decreasing airway and respiratory adverse events.

Objective: To assess the ability of ED tympanometry to identify those children with acute otitis media who are at greater risk for treatment failure, recurrent infection, or persistent middle ear effusion. Methods: A prospective observational study was performed in the EDs of a county hospital and a university medical center. One hundred seventeen children, aged 5 months to 5 years, with acute otitis media and abnormal tympanometric patterns were categorized into three groups —low compliance, high pressure, and low pressure—based on the initial patterns. All the children received oral amoxicillin for ten days. They had repeat tympanometry and otoscopy at 14- and 60-day follow-up visits, and were followed to determine clinical outcomes. Results: Initial treatment success was equivalent for all groups: low compliance 93% (95% confidence interval 81%-97%), high pressure 91% (95% CI 71%-98%), and low pressure 89% (95% CI 59–99%). Rates of relapse, reinfection, 90-day non-recurrence, and persistent otoscopic and tympanometric middle ear effusion did not differ significantly between groups. Conclusion: ED tympanometry of children with acute otitis media is unable to provide prognostic information regarding treatment failure, recurrent infection, or persistent middle ear effusion.

Background: The prophylactic coadministration of atropine or other anticholinergics during dissociative sedation has historically been considered mandatory to mitigate ketamine-associated hypersalivation. Emergency physicians (EPs) are known to omit this adjunct, so a prospective study to describe the safety profile of this practice was initiated. Objectives: To quantify the magnitude of excessive salivation, describe interventions for hypersalivation, and describe any associated airway complications. Methods: In this prospective observational study of emergency department (ED) pediatric patients receiving dissociative sedation, treating physicians rated excessive salivation on a 100-mm visual analog scale and recorded the frequency and nature of airway complications and interventions for hypersalivation. Results: Of 1,090 ketamine sedations during the 3-year study period, 947 (86.9%) were performed without adjunctive atropine. Treating physicians assigned the majority (92%) of these subjects salivation visual analog scale ratings of 0 mm, i.e., “none,” and only 1.3% of ratings were ≥ 50 mm. Transient airway complications occurred in 3.2%, with just one (brief desaturation) felt related to hypersalivation (incidence 0.11%, 95% confidence interval = 0.003% to 0.59%). Interventions for hypersalivation (most commonly suctioning) occurred in 4.2%, with no occurrences of assisted ventilation or intubation. Conclusions: When adjunctive atropine is omitted during ketamine sedation in children, excessive salivation is uncommon, and associated airway complications are rare. Anticholinergic prophylaxis is not routinely necessary in this setting.

It has recently been suggested that peripheral nerve or plexus blocks performed with the use of a nerve stimulator at low currents (

The evolution of hypogean fauna in general and hypogean fishes in particular has been controversial. Explanations regarding the reduction or loss of phenotypic characters such as eyes and pigmentation range from neo-Lamarckism to neutral mutations, with ‘regressive evolution’ being a catch-all characterization for such processes. The assumptions required for special evolutionary mechanisms underlying the evolution of cave dwellers have been based on generalizations about the animals and their environments drawn from relatively few observations. The evidence offered for notions such as pre-adaptation of colonizing fauna and the purported impoverished nutrients in all caves is examined and it appears that the generalizations cannot be supported. Some major accomplishments in field and laboratory studies of hypogean fishes are summarized, including work highlighting developmental phenotypic plasticity. At the end, it is argued that evolution of hypogean fauna can be explained by well-known mechanisms within the current context of evolutionary biology.

One of the most intriguing questions in evolutionary biology is the degree to which behavior is a necessary consequence of morphology. We explore this issue by examining phototactic behavior in epigean (eyed surface-dwelling) and troglomorphic (blind cave) forms of the teleost Astyanax fasciatus whose eyes were modified during embryogenesis by removing one or both lens vesicles from the epigean form or by transplanting the lens vesicle from an epigean fish into the optic cup of a blind cave form. Lens removal results in eye degeneration and blindness in adult epigean fish, whereas lens transplantation stimulates growth of the eye, inducing the development of optic tissues in the normally eyeless adult cave fish. Photoresponsiveness was examined by placing fish in an aquarium with one half illuminated and the other half dark and scoring their presence in the illuminated or dark half. Both the eyeless epigean fish and cave fish with induced eyes are indifferent to the illumination whereas the surface forms are scotophilic, suggesting that optic development and phototactic behavior are decoupled.

Objectives: It is unclear whether ketamine induces subclinical respiratory depression when administered in dissociative doses intravenously (IV). The authors report a pilot study of capnography in emergency department (ED) pediatric patients receiving ketamine alone for procedural sedation, and describe serial measures of ventilatory response [end-tidal carbon dioxide (EtCO 2 ), respiratory rate, pulse oximetry]. Methods: The authors performed continuous capnography on a convenience sample of 20 ED pediatric patients who received ketamine 1.5 mg/kg IV for procedural sedation. Results: Continuous EtCO 2 and pulse oximetry remained essentially unchanged following ketamine injection, and no EtCO 2 levels > 47 mm Hg were noted at any point throughout sedation. Conclusions: No hypoventilation was observed in 20 ED pediatric patients receiving ketamine 1.5 mg/kg administered IV over 1 minute. The authors found no evidence of respiratory depressant properties for this dissociative agent.

The assessment of pre-procedure fasting and control of sedation depth are prominent elements of widely disseminated procedural sedation guidelines and of the Joint Commission on Accreditation of Healthcare Organizations' standards. Both exist primarily to minimize the risk of pulmonary aspiration of gastric contents. This paper critically examines the literature on pre-procedure fasting and controlling sedation depth in association with pulmonary aspiration, and interprets this evidence in the context of modern emergency medicine practice. The article reviews the pathophysiology of aspiration and changing concepts regarding aspiration risk over the last decade. After reviewing studies on aspiration risk during general anesthesia, the paper reviews the risk of aspiration during labor and delivery as a more appropriate comparison group for aspiration risk during emergency department procedural sedation and analgesia (ED PSA). It is noted that aspiration during ED PSA has not been reported in the medical literature and that aspiration during general anesthesia and labor and delivery is uncommon. The literature provides no compelling evidence to support specific fasting periods for either liquids or solids prior to PSA, and existing guidelines for elective patients are of necessity arbitrary and based upon consensus opinion. The article discusses the implications in the areas of training and preparedness, monitoring, and research for the emergency physician practicing PSA.

Objective: To prospectively derive high-yield criteria for the detection of clinically significant electrolyte abnormalities (CSEAs) in children presenting to the ED. Methods: A prospective, multicenter, observational study was performed at the EDs of 2 urban teaching hospitals, a university medical center, and a children's hospital with a combined census of >275,000 patient visits/year (100,000 visits for children

Objective: To determine the test performance of leukocytosis for identifying acute myocardial infarction (AMI) in patients with nondiagnostic ECGs, admitted to rule out AMI. Methods: A retrospective, comparative test performance study was conducted using patients admitted to a university teaching hospital to rule out AMI. Clinical and laboratory information was reviewed and hospital laboratory ranges were used to define threshold elevations: total creatine kinase (CK), 275 U/L; CK-MB, 7.5 μg/L; white blood cell (WBC) count, 11.5 × 109/L; and absolute neutrophil count (ANC), 8.0 × 109. Sensitivity, specificity, and predictive values of the total CK, CK-MB, WBC count, and ANC were calculated, and receiver operating characteristic (ROC) curves constructed. Test performances of marker combinations also were determined. Results: The initial WBC count was significantly higher for the subjects who had AMI (11.1 vs 8.8 × 109/L, p < 0.001). For the 688 subjects who had nondiagnostic ECGs, sensitivities for the initial total CK, CK-MB, WBC, and ANC were 39%, 73%, 35%, and 36%, respectively, while the corresponding specificities were 94%, 93%, 85%, and 86%. Logistic regression analysis confirmed leukocytosis as an independent predictor of AMI (adjusted odds ratio 4.08, 95% CI 1.73–9.63). While CK-MB alone was 73% sensitive for AMI, the decision rule of either an elevated CK-MB or an elevated WBC count increased this sensitivity to 88% (corresponding specificity 79%). Similarly, while CK-MB alone was 93% specific for AMI, the combination of an elevated CK-MB and an elevated WBC count increased this specificity to 99% (corresponding sensitivity 20%). Conclusions: Leukocytosis is significantly associated with AMI, and is a weak but independent laboratory predictor of this condition. In this preliminary study of admitted patients suspected of AMI, the combination of the WBC and the CK-MB may have, additional diagnostic value over an isolated CK-MB result. Neither parameter in isolation was satisfactorily sensitive for AMI. Prognostic assessment of the role of the WBC count in clinical decision making should address its complementary role to that of other clinical and ancillary test parameters.

Emergency physicians (EPs) are increasingly participating in international medicine in regions that are chronically medically underserved. In August 1994, a ten-member emergency medicine team from the Loma Linda University School of Medicine staffed a 70-bed bush hospital in the primitive highlands of Papua New Guinea, providing both outpatient and inpatient medical care. Typhoid fever, malaria, polio, and numerous other infectious diseases were encountered. Rampant local tribal warfare resulted in regular penetrating injuries from arrows, spears, and machetes. The expedition was judged highly successful, in that 1) substantial medical service was provided to tribespeople accustomed to minimal care, 2) education was provided to local health care providers, and 3) team participants became adept at managing medical conditions uncommon in industrialized societies, and gained valuable ethical and utilitarian perspectives regarding health care delivery in underserved areas. In this article the objectives, organization, and experiences of the team members are described. This information may encourage other EPs to participate in medical expeditions to the developing world, and to provide general principles to assist in their organization and implementation.

Objective To evaluate the safety profile of ketamine when used to facilitate surgical procedures in the less controlled setting of developing world, rural hospitals. Methods A survey addressing clinical experience with ketamine in the developing world was administered to a convenience sample of missionary physicians. Descriptive statistics are reported. Results Of the 172 surveyed physicians, 122 (71%) responded; 55 reported experience with ketamine. These physicians estimated a total of 12,844 administrations. The format of one procedural physician and a second trained anesthesiologist/anesthetist was unavailable in the practice of 59% of the responding physicians, and 34% routinely performed procedures while simultaneously supervising ketamine administration and monitoring its clinical effect. Pulse oximetry was used "often" or "always" by only 10% of the physicians. Cardiac monitoring and intermittent vital signs were used in only 19% and 45%, respectively. One unexplained pediatric death occurred during an unmonitored, unobserved ward recovery. An adult suffered cardiac arrest after a failed intubation attempt. Seventeen other complications possibly related to ketamine were apnea (n = 10), laryngospasm (n = 6), and aspiration (n = 1), all of which were transient and without sequelae. Physicians believed that recovery hallucinations and agitation were frequent in adults and unusual in children. Conclusions Death and other serious complications were rare in this survey reporting > 12,000 estimated ketamine administrations in the developing world. Although the limitations of survey data are recognized, the margin of safety with ketamine appears to be high, even when administered by non-anesthesiologists in settings lacking basic mechanical monitoring. These findings have important implications for the use of ketamine outside the controlled operating room environment in developed countries.

To explore sources of variation in tropical forest primate biomass, and, in particular, to test the hypothesis that soil conditions are a major ultimate determinant of the biomass of colobine monkeys and other primates, we compared data on the soils, vegetation, and primate community at a site in West Africa (Tiwai Island, Sierra Leone) with information from other sites, especially two other African sites (Douala-Edea in Cameroon, and Kibale Forest in Uganda). The biomass of eight anthropoid primate species in old secondary high forest on Tiwai was estimated from data on population densities assessed by transect samples combined with data on social group densities and individual body masses. Samples of soil and tree foliage were collected at the same site, and subjected to a variety of chemical and mechanical analyses. Our estimate of anthropoid biomass at Tiwai is 1229-1529 kg/kM2, including 682-889 kg/km2 of colobines. This is one of the highest primate biomasses recorded anywhere. The soils at Tiwai were found to be relatively high in sand content and low in pH, and to have low levels of mineral nutrients. Levels of condensed tannins in the mature foliage of the trees comprising a major part of the forest canopy were higher than at other sites, but the ratio of protein to fiber in this foliage was also higher than at any other site except Kibale. It is argued that a wide range of environmental factors affect primate population densities, and that nutrient-poor soils and high tannin levels in tree foliage do not necessarily produce a low primate (or colobine) biomass, as some earlier studies had suggested. Fur