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The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

As currently written, national regulatory guidance on procedural sedation has elements that are contradictory, confusing, and out of date. As a result, hospital procedural sedation policies are often widely inconsistent between institutions despite similar settings and resources, putting emergency department (ED) patients at risk by denying them uniform access to safe, effective, and appropriate procedural sedation care. Many hospitals have chosen to take overly conservative stances with respect to regulatory compliance to minimize their perceived risk. Herein, we review and critique standards and policies from the Centers for Medicare & Medicaid Services, The Joint Commission, state nursing boards, the Food and Drug Administration, and others with respect to their effect on ED procedural sedation. Where appropriate, we recommend modifications of and enhancements to their guidance that would improve the access of ED patients to modern, safe, and effective procedural sedation care.

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.

Out-of-hospital personnel worldwide calculate the 13-point Glasgow Coma Scale (GCS) score as a routine part of field trauma triage. We wish to independently validate a simpler binary assessment to replace the GCS for this task.We analyzed trauma center registries from Loma Linda University Health (2003 to 2015) and Denver Health Medical Center (2009 to 2015) to compare the binary assessment "patient does not follow commands" (ie, GCS motor score6) with GCS score less than or equal to 13 for the prediction of 5 trauma outcomes: emergency intubation, clinically significant brain injury, need for neurosurgical intervention, Injury Severity Score greater than 15, and mortality. As a secondary analysis, we similarly evaluated 3 other measures simpler than the GCS: GCS motor score less than 5, Simplified Motor Score, and the "alert, voice, pain, unresponsive" scale.In this analysis of 47,973 trauma patients, we found that the binary assessment "patient does not follow commands" was essentially identical to GCS score less than or equal to 13 for the prediction of all 5 trauma outcomes, with slightly superior positive likelihood ratios (eg, those for mortality 2.37 versus 2.13) offsetting slightly inferior negative ones (eg, those for mortality 0.25 versus 0.24) and its graphic depiction of sensitivity versus specificity superimposing the GCS prediction curve. We found similar results for the 3 other simplified measures.In this 2-center external validation, we confirmed that a simple binary assessment-"patient does not follow commands"-could effectively replace the more complicated GCS for field trauma triage.

Background: The incidence of sedation-related adverse events, inclusive of both adults and children, administered by multiple specialty providers from different countries and venues, using standardized definitions, has never been reported on an international level. We are reporting the outcome data of the adverse event sedation reporting tool as an important step toward a more complete risk assessment of sedation-related morbidity, mortality, and etiology. The analysis of the AE sedation reporting data include descriptive measures to evaluate the characteristics of the provider, the patient, sedations performed, adverse events, interventions, and outcomes. The primary outcome was the rate and nature of adverse events. Between 12/14/2010 and 12/11/2018 there were 7952 sedations, from an estimated total of 164,114 sedations administered, of which 622 were reported as adverse events. The mean age of the entire patient population is 33.0 years (0.02–98.7). The providers represented 39 countries across six continents. Oxygen desaturation (75%–90%) for

In the late 1980s, undertreated pain became a focus of many clinicians, investigators, and industry. We coined a term, oligoanalgesia, to embolden earlier, titrated opioids and other analgesic use. Regulators mandated pain assessments and actions as a part of health care facility credentialing, and the prescribing of opioids increased yearly from 1990 to 2010. We now sit amid another opioid epidemic with death and disability. Many know of the patterns of use and abuse near the turn of the 20th century when opium was a new agent; this triggered opioid regulations and control, notably, the US Harrison Narcotics Tax Act of 1914 criminalizing nonmedical use. Despite regulation of opioids, swings upward in medical and nonmedical use exist in recent modern times. For example, a 1959 Readers Digest article noted a current opioid addiction crisis, reminding us that the cycles reappear often, with varying frequency, responses, and consequences. The current opioid upswing is rooted in prescribed and illicit use, the latter including heroin (or other “street” opioids) and diversion of another’s or factitious gain of a prescribed opioid. The widespread increase in opioid use correlates with increased overdose deaths and deaths in all segments, including more affluent and suburban or rural groups, not just in an inner-city or isolated population. Although the peak of the current wave crested in approximately 2010, we retain a large group with this affliction. This triggered calls for regulation and control in many facets of opioid deployment, including emergency care, despite few data suggesting a clear link between emergency department (ED) opioid use and later harm. Some seek governmental ED dose restrictions, and others call for “an opioid-free ED.” The goal of these calls to action is good: to avoid opioid harm, notably, death. At the

We review the literature in regard to the accuracy, reliability, and feasibility of the Mallampati score as might be pertinent and applicable to emergency department (ED) airway management and procedural sedation. This 4-level pictorial tool was devised to predict difficult preoperative laryngoscopy and intubation, but is now also widely recommended as a routine screening element before procedural sedation. The literature evidence demonstrates that the Mallampati score is inadequately sensitive for the identification of difficult laryngoscopy, difficult intubation, and difficult bag-valve-mask ventilation, with likelihood ratios indicating a small and clinically insignificant effect on outcome prediction. Although it is important to anticipate that patients may have a difficult airway, there is no specific evidence that the Mallampati score augments or improves the baseline clinical judgment of a standard airway evaluation. It generates numerous false-positive warnings for each correct prediction of a difficult airway. The Mallampati score is not reliably assessed because independent observers commonly grade it differently. It cannot be evaluated in many young children and in patients who cannot cooperate because of their underlying medical condition. The Mallampati score lacks the accuracy, reliability, and feasibility required to supplement a standard airway evaluation before ED airway management or procedural sedation.

Annals of Emergency Medicine - In Press.Proof corrected by the author Available online since dimanche 21 decembre 2014

Clinical decision rules are everywhere in medicine today. These impressive-looking decision algorithms and scoring systems are widely promoted as tools to either improve diagnosis or decrease expensive testing. As clinicians, we find decision rules psychologically appealing because they would appear to create order out of disorder. Medicine is inherently subjective; however, decision rules strive to transform such murky complexity into structured and tangible tools. Certainly a scientific decision instrument statistically derived from 10,000 or more patients must be superior to the frailty and variability of clinician judgment, mustn’t it? Many would assume so. Despite their many strengths, decision rules can also have important limitations. Before adoption, I suggest that readers scrutinize each such rule on the following questions. Three high-quality articles in this issue of Annals will help illustrate the principles discussed—the first a derivation of a rule to decrease abdominal computed tomography (CT) in children with blunt torso trauma, the second a contrast of the relative accuracy of decision rules for pulmonary embolism risk stratification when compared with unstructured clinical judgment, and the third an attempted validation of the modified Alvarado score—a previously described decision rule for appendicitis.

Procedural sedation is an integral part of emergency medicine (EM) practice in the USA, Canada, Australia and New Zealand. These countries have produced a large, robust literature supporting the safe and efficacious use of ketamine, propofol and other ED sedation agents for managing procedural pain and anxiety.1–3 In the UK and Ireland, EM and paediatric EM practitioners are striving to similarly establish procedural sedation as a fundamental part of their practice. McCoy et al describe, through a structured interview session with a group of EM consultants, the current issues impacting procedural sedation in the UK and the barriers to its adoption. Many of these same challenges and impediments were encountered in North America and Australia/New Zealand, and the lessons learned may be applicable and helpful in the UK and Ireland.4 As veterans of these challenges, here is our perspective. The capability of paediatric emergency physicians to administer timely procedural sedation directly benefits patients and their families by providing a safe, effective and efficient outpatient way of managing procedural pain and anxiety. Emergency physicians from North America, Australia and New Zealand reading the McCoy et al report will be surprised by the acceptance of hospitalisation as standard practice for management of simple forearm fractures in children, especially in the UK where EM is an established specialty. Such an approach transforms a brief ED procedure and a 30–90 min recovery into an overnight bed, an admitting paediatrician, a theatre room and an anaesthetist. Instead of promptly returning to the comforts of home, …

Summary Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

It is time to abandon the Glasgow Coma Scale (GCS). As discussed below, this ubiquitous neurologic scoring system is confusing, unreliable, and unnecessarily complex, and its manner of common clinical use is statistically unsound. Teasdale and Jennett devised the GCS in 1974 not for acute care, but rather for the “repeated bedside assessment” in a neurosurgical unit to detect “changing states” of consciousness and to measure the “duration of coma.” They never intended for its elements to be assigned numeric scores or for its 3 subscales to be merged or totaled. Yet, despite their objections both such dubious modifications subsequently proved irresistible to the medical community. The quantitative GCS subsequently has become the undisputed universal criterion standard for mental status assessment and is thus a fundamental part of the culture of emergency medicine, out-of-hospital care, trauma surgery, and neurosurgery. This scale is a core component of prominent trauma and life support courses, and in most of the developed world out-of-hospital care providers routinely assess the GCS for each patient with trauma or altered mental status. The original GCS article has been cited almost 6,000 times. This editorial outlines the potent limitations of the GCS and why it should now be considered obsolete within acute care medicine. This scale might be useful, however, for detecting subtle neurologic changes over time in an ICU (as originally envisaged). Curiously, though, it has never been validated for this separate role.

INTRODUCTION Procedural sedation refers to the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate unpleasant procedures while preserving cardiorespiratory function. Procedural sedation and analgesia is a core competency in emergency medicine and a daily part of emergency department (ED) practice. As noted by the United States Centers for Medicare & Medicaid Services (CMS): “The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality.” The CMS guidelines also state that “. . . emergency medicine–trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general).” Emergency medicine residency and pediatric emergency medicine fellowship core curricula include all of the requisite procedural sedation skills, eg, advanced airway management, resuscitation, critical care, monitoring, sedation pharmacology, pain management. Emergency physicians have a wellestablished track record of safe sedation and are important research and thought leaders in this multidisciplinary field. The American College of Emergency Physicians (ACEP) is an authoritative body that has established guidelines for the use of sedation, analgesia, and anesthesia by emergency physicians. CMS guidelines support the use of the ACEP guideline: “A hospital could use multiple guidelines, for example, ACEP for sedation in the ED and American Society of Anesthesiologists (ASA) for anesthesia/sedation in surgical services, etc.” ACEP convened this task force in 2011 to provide this update to guide hospital policy for the administration of analgesia, sedation, and anesthesia by emergency physicians.

The objective of this study was to assess predictors of emergency department (ED) ketamine-associated laryngospasm using case-control techniques.We performed a matched case-control analysis of a sample of 8282 ED ketamine sedations (including 22 occurrences of laryngospasm) assembled from 32 prior published series. We sequentially studied the association of each of 7 clinical variables with laryngospasm by assigning 4 controls to each case while matching for the remaining 6 variables. We then used univariate statistics and conditional logistic regression to analyze the matched sets.We found no statistical association of age, dose, oropharyngeal procedure, underlying physical illness, route, or coadministered anticholinergics with laryngospasm. Coadministered benzodiazepines showed a borderline association in the multivariate but not univariate analysis that was considered anomalous.This case-control analysis of the largest available sample of ED ketamine-associated laryngospasm did not demonstrate evidence of association with age, dose, or other clinical factors. Such laryngospasm seems to be idiosyncratic, and accordingly, clinicians administering ketamine must be prepared for its rapid identification and management. Given no evidence that they decrease the risk of laryngospasm, coadministered anticholinergics seem unnecessary.

IMPORTANCE: It is not clear whether adherence to preprocedural fasting guidelines prevent pulmonary aspiration and associated adverse outcomes during emergency department (ED) sedation of children. OBJECTIVE: To examine the association between preprocedural fasting duration and the incidence of sedation-related adverse outcomes in a large sample of children. DESIGN, SETTING, AND PARTICIPANTS: We conducted a planned secondary analysis of a multicenter prospective cohort study of children aged 0 to 18 years who received procedural sedation for a painful procedure in 6 Canadian pediatric EDs from July 2010 to February 2015. The primary risk factor was preprocedural fasting duration. Secondary risk factors were age, sex, American Society of Anesthesiologists classification, preprocedural and sedation medications, and procedure type. MAIN OUTCOMES AND MEASURES: Four outcomes were examined: (1) pulmonary aspiration, (2) the occurrence of any adverse event, (3) serious adverse events, and (4) vomiting. RESULTS: A total of 6183 children with a median age of 8.0 years (interquartile range, 4.0-12.0 years), of whom 6166 (99.7%) had healthy or mild systemic disease (American Society of Anesthesiologists levels I or II), were included in the analysis. Of these, 2974 (48.1%) and 310 (5.0%) children did not meet American Society of Anesthesiologists fasting guidelines for solids and liquids, respectively. There were no cases of pulmonary aspiration. There were 717 adverse events (11.6%; 95% CI, 10.8%-12.4%), of which 68 (1.1%; 95% CI, 0.9%-1.3%) were serious adverse events and 315 (5.1%; 95% CI, 4.6%-5.7%) were vomiting. The odds ratio (OR) of occurrence of any adverse event, serious adverse events, and vomiting did not change significantly with each additional hour of fasting duration for both solids (any adverse event: OR, 1.00; 95% CI, 0.98 to 1.02; serious adverse events, OR, 1.01; 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.97-1.03) and liquids (any adverse event: OR, 1.00; 95% CI, 0.98-1.02; serious adverse events: 1.01, 95% CI, 0.95-1.07; vomiting: OR, 1.00; 95% CI, 0.96-1.03). CONCLUSIONS AND RELEVANCE: In this study, there was no association between fasting duration and any type of adverse event. These findings do not support delaying sedation to meet established fasting guidelines.

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.

We wished to compare the acuity of adults vs. children using a representative sample drawn from a geographically isolated region. We retrospectively analyzed Emergency Department (ED) patient logs, billing records, and trauma data from two hospitals serving a geographically isolated region (Santa Barbara, California), and compared the following measures of acuity by age, triage category, rates of admission, billing levels of service, procedures (ED intubation, cardiopulmonary resuscitation, and invasive line placement), and trauma team activations. We analyzed 88,864 patients treated at the two EDs over an 18-month period, of whom 15,589 (17.5%) were children (18 years of age). Adults were 1.93 times more likely than children to receive the highest triage category (95% confidence interval [CI] 1.65-2.27), 3.47 times more likely to be admitted (95% CI 3.26-3.70), 2.92 times more likely to receive critical care or extended examination billing (95% CI 2.78-3.06), 2.63 times more likely to be intubated (95% CI 1.78-3.88), 4.59 times more likely to receive cardiopulmonary resuscitation (95% CI 1.67-12.57), and 4.39 times more likely to receive invasive line placement (95% CI 1.93-10.01). No age-based differences were noted in the rates of highest-level trauma team activation or admission directly to the operating room. ED children have overall lower acuity than ED adults-by many measures, several-fold less. These findings may have important implications for ongoing skills retention and proficiency in critical care for practitioners whose ED practice is restricted to representative samples of children.

Rodent and monkey research has shown that ketamine can induce accelerated programmed nerve cell death (apoptosis) when administered in high doses, for prolonged periods, or both. Concern about similar neurotoxicity with human therapeutic use has prompted ongoing investigations by the Food and Drug Administration and National Institutes of Health. If the results of these inquiries are unfavorable to ketamine, such action could ultimately lead to restricted availability of this drug or even its discontinuation from the market. This article discusses the limitations of the published animal research, the challenges in extrapolating such data to humans, the need for further animal and human investigations, and the potential adverse effect on current clinical practice that might result, should the use of ketamine be restricted or the drug removed from the market.

Propofol is rapidly becoming one of the most popular procedural sedation and analgesia agents in emergency medicine. However, in many hospitals emergency physicians lack access to this potent sedative. This article details the evidence and politics underlying this area of controversy, the nature and authority of hospital-wide sedation policies, and discussion of the most common criticisms of emergency department use of propofol.

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.

The practice of procedural sedation and analgesia in pediatrics is evolving rapidly. Some of our practices are backed by substantial supporting data, whereas for others, the evidence base is less well developed, leading to substantial differences in provider preferences. In addition, the multidisciplinary nature of providing sedation and differences in local custom and regulatory requirements all contribute to a certain amount of practice variability: the “art” of sedation. To provide a forum for exploring this, we invited experts in pediatric procedural sedation to share their practices and “pearls”, combining anecdotal experience with evidence from the literature.

Emergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. The advisory is not intended to assert a legal standard of practice or absolute requirement. It is expected that emergency physicians will at times appropriately deviate from it according to individualized judgment and unique clinical circumstances.

Clinical decision rules are common and widely promoted in emergency medicine, yet their quality varies widely. Few decision rules undergo the rigorous external validation necessary to confirm their function, as should appropriately occur before their incorporation into clinical practice. This issue of Annals features 3 articles on urolithiasis, including 2 on a clinical decision rule called the STONE score. Wang et al report a large and compelling external evaluation, the original STONE investigators test whether ultrasonography enhances score performance, and Wang provides a short review of urolithiasis management. These articles—in particular the external evaluation by Wang et al—illustrate key principles about clinical decision rule validity, purpose, and function that can be applied when evaluating other rules. We will discuss 4 such issues here, referring readers interested in greater background discussion to Annals’ guidelines for the appraisal of clinical decision rules.

Background We hypothesised the addition of brief empathetic statements to physician–patient interaction might decrease thoughts regarding litigation. Methods We enrolled a convenience sample of adults in our emergency department (ED) waiting room into a randomised, double-blind controlled trial. Subjects watched videos of simulated discharge conversations between physicians and patient actors; half of the videos differed only by the inclusion of two brief empathetic statements: verbalisations that (1) the physician recognises that the patient is concerned about their symptoms and (2) the patient knows their typical state of health better than a physician seeing them for the first time and did the right thing by seeking evaluation. After watching the video subjects were asked to score a five-point Likert scale their thoughts regarding suing this physician in the event of a missed outcome leading to lost work (primary outcome), and four measures of satisfaction with the physician encounter (secondary outcomes). Results We enrolled and randomised 437 subjects. 213 in the empathy group and 208 in the non-empathy group completed the trial. Sixteen subjects did not complete the trial due to computer malfunction or incomplete data sheets. Empathy group subjects reported statistically significant less thoughts of litigation than the non-empathy group (mean Likert scale 2.66 vs 2.95, difference −0.29, 95% CI −0.04 to −0.54, p=0.0176). All four secondary measures of satisfaction with the physician encounter were better in the empathy group. Conclusions In this study, the addition of brief empathetic statements to ED discharge scenarios was associated with a statistically significant reduction in thoughts regarding litigation. Clinical trial registration NCT01837706.

INTRODUCTION As a peer-reviewed scientific journal, Annals of Emergency Medicine is reliant on its volunteer team of expert reviewers to assess the suitability of articles for publication. In 2005, Annals received 1,231 total submissions, of which 521 underwent external peer review, including 67% of the original research articles submitted. Our referees performed 1,317 total reviews, an average of 2.5 per reviewed article. Although the peer-review process lies at the heart of the dissemination of science, many authors and readers find it mysterious. In this article, we wish to summarize the current system of peer review at Annals, answer the most common questions we receive, and describe recent progress in our review process since our adoption of an electronic article processing system (Editorial Manager; Aries Systems Corporation, North Andover, MA) in January 2002.

We present an evidence-based clinical practice guideline for the administration of the dissociative agent ketamine for emergency department pediatric procedural sedation and analgesia. Substantial research in recent years has necessitated updates and revisions to the widely disseminated 1990 recommendations. We critically discuss indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, recovery issues, and future research questions for dissociative sedation.

Is propofol an appropriate agent for use as part of emergency department (ED) procedural sedation and analgesia? Few questions in emergency medicine are currently as controversial. No one disputes that propofol exhibits numerous exceptionally desirable characteristics as a procedural sedation and analgesia agent. First, its clinical effect is essentially immediate after intravenous administration (“one arm–brain circulatory time”). Second, its marked potency reliably produces effective procedural sedation and analgesia conditions, even for very painful procedures. Third, recovery after sedation is extremely short, typically between 5 and 15 minutes. Finally, patient satisfaction is high because propofol has anti-emetic and apparent euphoric properties. It is no wonder that this agent has revolutionized anesthesiology practice. Many emergency physicians have already extrapolated this proven operating room success to our setting, using propofol as a single agent or in combination with an opioid, to successfully induce brief but potent sedation for short, painful procedures such as orthopedic manipulations, cardioversion, and abscess drainage. However, this application is based on limited experience because, thus far, only 8 small series of ED propofol use have been formally reported (Table).1-8 Despite this, proponents believe that there are sufficient studies in the anesthesia literature demonstrating the safety and efficacy of propofol to justify its use in the ED.9 Although hypotension, apnea, pain on injection, and bacterial contamination of the lipid emulsion have been reported, the primary criticism of propofol for procedural sedation and analgesia has focused on the greater sedation depth that typically results from propofol. Using the traditional propofol for procedural sedation and analgesia combination of midazolam and fentanyl, emergency physicians can reliably (albeit laboriously) titrate patients to either a state of “moderate sedation” (ie, purposeful responsive to verbal or tactile stimulation)10 or “deep sedation” (ie, purposeful responsive to repeated or painful stimulation).10 It is widely accepted that such moderate sedation is unlikely to be associated with impairment of protective airway reflexes, and thus aspiration risk in this setting is minimized.11 In contrast, however, the ultrarapid onset and high potency of propofol make it more difficult to titrate and prone to potentially substantial overshoot. Within 30 seconds of a single intravenous dose of propofol, a patient’s sedation depth could, without always a high level of predictability, be compatible with moderate sedation, deep sedation, or perhaps general anesthesia.12 Although all nondissociative sedatives can induce depth at all levels of the sedation continuum, in practice, propofol is primarily used for deep sedation.3-8,13 Anesthesiologists have been especially concerned about propofol use by nonanesthesiologists14 and have not differentiated such practitioners by skill set, lumping together emergency physicians with dentists, radiologists, and gastroenterologists.15,16 Pharmacy and therapeutics committees in many hospitals have blocked use of propofol for ED procedural sedation and analgesia because of objection by anesthesiologists on the committee. The paucity of data on the safety of propofol for ED procedural sedation and analgesia has made it difficult at times to overcome these objections. Four years ago, one of us characterized propofol as “not yet ready for prime time” in emergency medicine.12 This cautionary commentary raised concerns regarding the risk of inadvertent oversedation with propofol, personnel requirements, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, and fasting in the setting of deep sedation. Large case P A I N M A N A G E M E N T / E D I T O R I A L

Preoperative fasting guidelines promulgated by the American Society of Anesthesiologists (ASA) have, with little discussion, been extrapolated outside of the operating room to include procedural sedation and analgesia. These guidelines stipulate at least 2 hours of fasting for clear liquids, at least 4 hours for breast milk, and at least 6 hours for solids, cow’s milk, and infant formula.1 Despite a general acceptance that most procedural sedation and analgesia techniques—particularly moderate and dissociative sedation—are not likely to produce a loss of protective airway reflexes,2-6 the ASA believes that fasting for even light preprocedural sedation should be as long as that for general anesthesia.1 These stringent ASA fasting guidelines have been widely disseminated and codified into hospital-wide sedation policies, and many emergency departments (EDs) have found their procedural sedation and analgesia practices affected by resulting institutional fasting dictates. These directives have encountered surprisingly little resistance, no doubt because essentially all practitioners outside of the ED administer procedural sedation and analgesia for scheduled, elective procedures. Minimal extra effort is required for the support staff of gastroenterologists, cardiologists, radiologists, and oncologists to instruct patients to fast in advance of P E D I A T R I C S / E D I T O R I A L

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.

ors are inexperienced, poorly trained, or cursory. Analgesic orders may be poorly legible or use trade names or jargon (eg, “M.S.”) unfamiliar to data abstractors. The National Hospital Ambulatory Medical Care Survey database, despite its many strengths, remains at its core a large chart review with data abstracted by government census personnel or hospital medical records staff. Unfortunately, researchers have no way to independently verify the quality and accuracy of the aggregated survey data. In 2010 Schuur et al observed that only 56% of women with an International Classification of Diseases, Ninth Revision diagnosis of ectopic pregnancy were coded as having received a pregnancy test, despite this diagnosis inherently requiring verification of pregnancy. If abstractors are unable to reliably code pregnancy testing, what similar errors may occur with analgesia? In oligoanalgesia research, instances in which actual analgesia is either not documented or not correctly abstracted are coded as improper physician care. What about competing priorities? Treating pain is a high priority for emergency physicians, but not always the highest. When resuscitations or critical procedures are under way, other patients will need to wait. Decreased analgesia has been demonstrated in settings of ED crowding and may at times be unavoidable. In oligoanalgesia research, instances in which analgesia is appropriately deferred by competing priorities are coded as improper physician care. What about publication bias? Oligoanalgesia attracts big attention, especially if racism, sexism, or age discrimination is implied. When researchers discover tantalizing effects they are more likely to finish and submit their studies, and journals are more likely to publish them. Such publication bias is a major problem in science, and hot areas such as oligoanalgesia are likely to be the most susceptible to this prejudice. Who knows how many pain studies were abandoned or rejected as too unexciting when their analyses found satisfactory or equitable analgesia? The studies with positive results are the ones publicized and cited; however, there are plenty of studies with negative results that, despite publication bias, have found their way into the literature. Although some researchers found ethnic differences in pain management, others did not. One study reported less analgesia in female patients; however, several others did not. As amply highlighted by the 2 t Volume , .  : August  ontrasting studies in this issue of Annals, some researchers escribe oligoanalgesia in the elderly, whereas others do ot. Children were undertreated according to some uthors, whereas others found no such effect or ctually reported superior analgesia. Given such conflicting data, any presumption that mergency physicians are discriminatory is far from conclusive. What about differential expectations? Perhaps certain subsets of atients are more likely than others to show their pain or to request nalgesics. This could explain apparent differences in analgesic dministration. Physicians might tailor their analgesia not to race, but ather their differential perceptions of patient expectations, potential omplaints, and litigation risk. This alternative explanation is supported y the observation in 2 studies that minority physicians displayed the ame treatment differences as white physicians: both administered ore analgesia to whites. Ultimately, any assessment of appropriate analgesia ranscends just a pain score and instead represents a complex nteraction of patient wishes, physician perception and udgment, and other circumstantial factors, something quite ifficult to assess with hindsight. As noted with the multiple arguments above, the prevalence and ature of oligoanalgesia may be substantially exaggerated. Despite this, he Joint Commission (TJC) has stepped in to ostensibly improve ED ain management by mandating that hospitals record pain scores. nfortunately, patient-reported scores do not reliably predict which atients desire analgesics, and physicians do not use such scores as the asis for their treatment. Mandating pain scoring at triage does ncrease the frequency of analgesic administration, but is this ctually improving care for our patients? Or instead is it simply ounding us to pressure patients to receive analgesics that they don’t ant? As with other notable TJC performance initiatives, this pain coring may alter measurable intermediate outcomes of debatable mportance but fail to achieve its ultimate objective of benefitting atients. So what to do? I suggest that it is now time for oligoanalgesia esearch to move beyond its flawed retrospective format, which as yielded contradictory and inflammatory results. Future esearch should instead prospectively assess when patients ctually want analgesia and whether they then receive it when ppropriate. This is the true patient-oriented bottom line and he optimal standard by which appropriate pain management hould be judged. Certainly emergency physicians should be carefully attuned o each patient’s pain and liberally offer analgesics when ppropriate. No doubt each of us has room for some mprovement in this area. However, the notion that nacceptable degrees of oligoanalgesia have been or continue to e rampant in emergency medicine is likely dramatically verstated, if not outright mythical. upervising editor: Michael L. Callaham, MD. unding and support: By Annals policy, all authors are required o disclose any and all commercial, financial, and other Annals of Emergency Medicine 213

Southern Pacific rattlesnake (Crotalus helleri ) venom is not 1 of the 4 venoms used to produce Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV). There is currently no published clinical experience regarding the efficacy of this new antivenom for confirmed C helleri envenomation, and animal data suggest greatly diminished efficacy. We assessed the efficacy of FabAV for patients with confirmed C helleri envenomation.We conducted a prospective observational study of 23 consecutive rattlesnake envenomations that were treated with FabAV at our center. Patients were excluded if the species of snake could not be confirmed, if FabAV antivenom was not given, or if Antivenin (Crotalidae) polyvalent (equine) was given. We collected serial physical examination and laboratory data over a 24-hour period to serially evaluate the severity score and performed follow-up to evaluate delayed reactions.There were 15 patients who received FabAV and had the species of rattlesnake confirmed (9 C helleri, 4 C scutulatus scutulatus, 1 C mitchellii pyrrhus, 1 C ruber ruber ). C helleri envenomations demonstrated similar improvement in serial snakebite severity scores to those of other species. Three patients treated with scheduled dosing had recurrence of progressive swelling (2 C helleri and 1 C mitchellii pyrrhus ) during the 24-hour study period.We observed similar improvement in FabAV-treated patients with C helleri envenomation compared with those of other species and conclude that this treatment in standard doses appears efficacious for bites by this species. Progressive swelling may recur despite scheduled dosing.

To develop a clinical decision rule for predicting significant chest radiography abnormalities in adult Emergency Department (ED) patients, a prospective, observational study was conducted of consecutive adults (or=18 years old) who underwent chest radiography for nontraumatic complaints at an urban ED with an annual census of 85,000. The official radiologist interpretation of the film was used as the gold standard for defining radiographic abnormalities. Using predefined criteria and author consensus, patients were divided into two groups: those with clinically significant abnormalities (CSA) and those with either normal or nonclinically significant abnormalities. Chi square recursive partitioning was used to derive a decision rule. Odds ratios and kappa statistics were calculated for derived criteria. The results showed 284 (17%) of 1650 patients had clinically significant abnormal radiographs. The presence of any of 10 criteria (ageor= 60 years, temperatureor= 38 degrees C, oxygen saturation90%, respiratory rate24 breaths/min, hemoptysis, rales, diminished breath sounds, a history of alcohol abuse, tuberculosis, or thromboembolic disease) was 95% sensitive (95% CI: 92-98%) and 40% specific (95% CI: 37-43%) in detecting CSA radiographs. Positive and negative predictive values were 25% (95% CI: 23-27%) and 98% (95% CI: 96-99%), respectively. A highly sensitive decision rule for detecting clinically significant abnormalities on chest radiographs in nontraumatized adults has been developed. If prospectively validated, these criteria may permit clinicians to confidently reduce the number of radiographs in this population.

[Green SM, Rothrock SG. Is pediatric trauma really a surgical disease? Ann Emerg Med. May 2002;39:537-540.]