UCONN Emergency Medicine Interest Group

Posts Tagged ‘anesthesia’

Book Review: Wounds and Lacerations – Emergency Care and Closure

In REVIEWS on June 3, 2011 at 6:19 PM

This review is for the book Wounds and Lacerations: Emergency Care and Closure, 3rd edition by Alexander T. Trott, MD, which can be purchased here. The reviewer has received no financial renumeration for this review.

This is a book which I picked up for my outpatient surgery clerkship in preparation for both that rotation and my upcoming EM rotations. I had hoped to learn from a reputable source the very basics involved in wound repair, which I felt were somewhat lacking in the general curriculum, as well as some advanced techniques. I was looking for a book that was evidenced-based, rather than tradition-based, and covered a fair amount of ground while not being overly arduous to get through in a 3 week period.

Overall, I feel that this book fulfilled those goals, and generally quite well. The text of the book, not including the index, is 316 pages long and divided into 22 chapters. It begins with an overview of emergency wound care and assessment, and gradually builds up in a logical succession in a sequence of how you would close a wound in the ED, beginning with assessment, followed by anesthesia, then cleansing, then choosing suture material and instruments, then techniques both for repairing simple and complex wounds. The book then transitions to special situations, such as facial or hand wounds, bites, burns, foreign body removal, etc. The book makes sure to cover even the “simple” but essential issues involved in wound care which are probably not ever going to be formally taught. For example, in the chapter on wound cleansing, there are subsections dedicated to what sort of solutions to use, how to irrigate properly and with the correct instrument, positioning the patient, and so on. Likewise, there is a 28-page chapter on wound dressing and bandaging with copious illustration.

Strengths of the book included brevity of the writing and many illustrations (tri-color only, unfortunately) and attention to all portions of wound care in a primary survey of the subject. Weaknesses included the fact that the text and the illustrations were sometimes a bit awkwardly out of sync, which might be confusing if attention was not paid to which figure number in the text matched up to which figure (in other words, the figures on one page often were referenced to on the previous page, rather than the current page). The subsections could also sometimes occasionally be a little too brief, although I am hesitant to consider this a significant weakness, since it ensured that the most essentially information didn’t get lost in text (as I feel often happens in textbooks).

Overall score (out of 5 stars):

Journal Article Synopsis: Ketamine vs. Ketofol, an RCT

In JOURNAL CLUB on May 1, 2011 at 4:15 PM

Summary for “A Blinded, Randomized Controlled Trial to Evaluate Ketamine/Propofol Versus Ketamine Alone for Procedural Sedation in Children” by Amit Shah et al. in Annals of Emergency Medicine Vol 57 (5); pp 425 -433

What is already known on this topic:
Ketamine is a well-established agent used for procedural sedation of children in the Emergency Department.   However, ketamine recovery times can be lengthy and have been shown to range from 25-108 minutes.  Recently, the use of propofol for procedural sedation has become more popular given its favorable pharmokinetics and adverse events profile.  The disadvantage of propofol is the risk of dose-dependent respiratory depression.

Recent studies have demonstrated the safety of administering ketamine and propofol together.  The premise behind administering both medications together, is that it allows for a dose reduction in each medication and thus decreases the risk of respiratory depression.  In addition, ketamine and propofol exhibit several opposite qualities, which may complement each other for a more favorable side effect profile (i.e.  ketamine is emetogenic while propofol has antiemetic properties; ketamine often produces post procedural agitation, while propofol has anxiolytic properties; ketamine maintains respiratory drive, while propofol depresses repiratory drive; ketamine provides an element of analgesia which propofol is lacking)

What question this study addressed:
Is there a clinically significant decrease in total sedation time (10 minutes or more) when using ketamine plus propofol compared to the use of ketamine alone for pediatric procedural sedation?

Secondarily, is there a significant difference in time to recovery, adverse events, efficacy, or satisfaction scores between ketamine plus propofol or ketamine alone?

What was the study design:
Blinded, randomized, controlled trial including 136 pediatric patients requiring procedural sedation for an isolated orthopedic injury.

What this study adds to our knowledge:
The use of ketamine plus propofol compared to the use of ketamine alone reduced the total sedation time by 3 minutes (p=0.04).  In addition, ketamine plus propofol demonstrated a 10% reduction in vomiting compared to ketamine alone (95% CI  -18% to -2%).  Finally, satisfication scores were higher with the ketamine/propofol group (p<0.05).  There was no statistical difference between the two groups with respect to efficacy or airway complications.

How this is relevant to clinical practice:
The combination of ketamine plus propofol for procedural sedation only minimally reduces total sedation time (3 minutes) making it questionable as to whether or not this is clinically significant.  However, ketamine plus propofol does decrease the incidence of vomiting and has a higher rate of satisfaction among patients, nurses, and physicians.

Other considerations:
It would be interesting to compare ketamine plus propofol to propofol alone for pediatric procedural sedation.

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