2007 CAEP/ACMU Scientific Abstracts - Plenary Presentations: 46-48

2007 Scientific Abstracts

CJEM 2007;9(3):183-226

Abstracts: 1-30, 31-44, 46-48, 100-130, 131-159, 161-189, 191-216

Plenary Presentations

46 LOW-DOSE ketamine versus fentanyl as adjunct analgesic to procedural sedation with propofol: a randomized, clinical trial

Messenger DW, Murray HE, Dungey PE, VanVlymen J, Sivilotti MLA. Department of Emergency Medicine, Queen's University, Kingston, ON

Introduction: Opioid analgesics may compound the cardiorespiratory depressant effects of propofol, a popular agent for ED procedural sedation and analgesia (PSA). The use of low-dose ketamine as an adjunct analgesic may cause fewer adverse effects than the propofol-opioid combination. Methods: This double-blind, randomized trial enrolled patients aged 14-65 years (ASA Class I or II), requiring PSA for orthopedic reduction or abscess drainage in an academic ED. Subjects received ketamine 0.3 mg/kg or fentanyl 1.5 μg/kg IV, followed by titrated IV propofol to reach deep sedation. The primary outcome was the incidence of cardiorespiratory adverse events, using a novel scoring tool (none, mild, moderate, severe). Secondary outcomes included adverse event frequency, propofol doses required to achieve/maintain sedation, times to sedation/recovery, and physician/patient satisfaction. Results: The trial was terminated by the independent data safety monitoring committee after a planned interim analysis. Sixty-three of a planned 124 patients were enrolled. Of patients who received fentanyl, 26/31 (83.9%) had an adverse event, usually reversible hypoxemia, versus 15/32 (46.9%) of those who received ketamine. Moderate or severe adverse events were seen in 16/31 (51.6%) of fentanyl subjects versus 7/32 (21.9%) of ketamine subjects (OR 12.3, p<0.001). After adjustment for gender, age and procedure type, fentanyl subjects had 4.6 (95% CI 1.4-15.3) times the odds of having a higher adverse event severity score than ketamine subjects. There were no significant differences in secondary outcomes, apart from higher propofol doses in the ketamine arm. Conclusions: This RCT shows that low-dose ketamine is significantly safer than fentanyl for ED PSA with propofol and has similar efficacy, notwithstanding higher propofol doses in the ketamine arm. Key Words: Procedural sedation, Propofol, Ketamine, Fentanyl

47 MULTICENTER controlled clinical trial to evaluate the impact of advanced life support on children with out-of-hospital respiratory distress

Osmond MH, Stiell IG, Nesbitt L, Clement CM, Campbell S, Munkley D, Luinstra-Toohey L, Maloney J, Wells GA, for the OPALS Study Group. Department of Emergency Medicine, University of Ottawa, Ottawa, ON

Introduction: There is little published evidence regarding the optimal EMS management of pediatric respiratory distress. Our study evaluated the impact of advanced life support (ALS) EMS programs on pediatric respiratory patient outcomes. Methods: This multicenter before-after controlled clinical trial was conducted in 17 communities as part of the Ontario Prehospital Advanced Life Support (OPALS) Study, which evaluates the impact of EMS programs for multiple conditions. During the before phase, care was provided at the BLS-D level. During the after phase, ALS providers administered nebulized and IV drugs and performed endotracheal intubation. Data were collected from ambulance reports, centralized dispatch data, and in-hospital records. Chi-square and Student's t-test analyses were performed. Results: The 1,257 patients enrolled during the two 24-month BLS and ALS phases were well matched for clinical and demographic features and had these characteristics: mean age 4.9 (0-15), male 56.1%, mean RR 31, chronic asthma 35.2%, chronic respiratory medications 34.5%. Bag valve mask ventilation was provided to 10 (1.6%) in the BLS phase and 9 (1.4%) in the ALS phase (P=.74). During the ALS phase, patients received these EMS interventions: nebulized salbutamol 39.6%, IV epinephrine 0.9%, intubation 1 (0.16%), IV access attempted 33 (5.1%), IV successful 24 (3.7%). There was no significant reduction from the BLS to the ALS phase in overall mortality (0.5% vs 0.2%; P=.30) or admission to hospital (26.0% vs 22.2%; P=.16). There was however a significant difference from the BLS to the ALS phase in admission to ICU (3.3% vs 1.4%; P=.046). Conclusions: This large controlled trial of children with respiratory distress shows that the addition of a system-wide EMS ALS program did not significantly improve patient survival or hospital admission but may decrease ICU admission. Few children transported with respiratory distress received assisted ventilation or advanced airway maneuvers. Key Words: EMS, Pediatric respiratory distress, ALS, BLS.

48 ANTIBIOTIC selection reduces relapse following emergency department discharge in patients with exacerbations of chronic obstructive pulmonary disease

Rowe BH, Aaron SD, Abu-Laban R, Stiell IG, Johnson J, Sivilotti M, Campbell S, Mackey D, Young B, Ross S, Walker A, Worster A, Sentilselvan A. Department of Emergency Medicine, University of Alberta, Edmonton, AB

Introduction: While antibiotics are recommended in patients discharged from the Emergency Department (ED) with chronic obstructive pulmonary disease (COPD) exacerbations, most comparisons have not involved concomitant systemic corticosteroids and the use of newer agents is increasing. This study compared a first line treatment to a newer more potent macrolide in acute COPD. Methods: This randomized, double-blind, double-dummy controlled clinical trial enrolled 159 patients with COPD exacerbation discharged from the ED. Patients were randomly assigned to treatment with oral doxycycline or clarithromycin for 10 days. All patients also received oral prednisone (40 mg once daily) for 10 days, plus as needed inhaled bronchodilators. All other COPD medications being taken by the patients at the time of enrollment were continued throughout the duration of the study in both treatment groups. The primary endpoint was relapse within 30 days of randomization, defined as an unscheduled visit to a physician's office, or a return to the ED, because of worsening dyspnea. Results: Patient demographics were similar in both groups; most patients were elderly (mean age = 68.2), male (54%), with > 40 pack years of smoking. The overall rate of 30-day relapse was significantly lower in the doxycycline-treated group compared to the clarithromycin group (19% vs 34%, P= 0.035); all cause (p=0.004) and respiratory-related (p=0.007) hospitalizations also favoured the doxycycline group. Both groups demonstrated improved 30-day FEV1 measures; however, there were no differences between the groups. Improvements in health-related quality of life were not significantly greater for those treated with doxycycline compared to clarithromycin (p>0.05). Side effects were uncommon and similar between groups. Conclusions: When combined with corticosteroid treatment, outpatient treatment with oral doxycycline offers a small advantage over clarithromycin in treating patients with COPD exacerbation who are discharged from the emergency department. Key Words: AECOPD, Relapse, Doxycycline, Clarithromycin