Introduction: Lacerations are common in children presenting to the emergency department (ED). They are often uncooperative when sutures are needed and may require procedural sedation. Few studies have evaluated intranasal (IN) ketamine for procedural sedation in children, with doses from 3 to 9 mg/kg used mostly for dental procedures. In a previous dose escalation trial, DosINK-1, 6 mg/kg was found to be the optimal IN ketamine dose for procedural sedation for sutures in children. In this trial, we aim to further evaluate the efficacy of this dose. Methods: We conducted a multicentre single-arm clinical trial. A convenience sample of 30 uncooperative children between 1 and 12 years (10 to 30 kg) with no cardiac or kidney disease, active respiratory infection, prior administration of opioid or sedative agents received 6 mg/kg of IN ketamine using an atomizer for their laceration repair with sutures in the ED. The primary outcome was defined as the proportion (95% CI) of patients who achieved an adequate procedural sedation evaluated with the PERC/PECARN consensus criteria. Results: Thirty patients were recruited from April 2018 to November 2019 in 2 pediatric ED. The median age was 3.2 (interquartile range(IQR), 1.9 to 4.7) years-old with laceration of more than 2 cm in 20 (67%) patients and in the face in 21 (70%) cases. Sedation was effective in 18 out of 30 children 60% (95%CI, 45 to 80), was suboptimal in 6 patients (20%) with a procedure completed with minimal difficulties, and unsuccessful in the remaining 6 (20%), all without serious adverse event. Similarly, 21/30 (70%) physicians were willing to reuse IN ketamine at the same doses and 25 parents (83%) would agree to the same sedation in the future. Median time to return to baseline status was 58 min (IQR, 33 to 73). One patient desaturated during the procedure and required transitory oxygen and repositioning. After the procedure, 1 (3%) patient had headache, 1 (3%) patient had nausea, and 2 (7%) patients vomited. Conclusion: A single dose of 6 mg/kg of IN Ketamine for laceration repair with sutures in uncooperative children is safe and facilitated the procedure in 60% (95%CI, 45 to 80) of patients, was suboptimal in 20% and unsuccessful in 20% of patients. As seen with IV ketamine, an available additional dose of IN ketamine for some children if needed could potentially increase proportion of successful sedation. However, the safety and efficacy of repeated doses needs to be addressed.

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients undergoing painful procedures through the use of procedural sedation (PS). While, PS is generally safe and effective in the ED, there is institutional variability and clinician disagreement with respect to the bedside equipment required for airway management and the monitoring of adverse events. The primary goal of this research project was to describe the variability of the bedside setup utilized by Canadian ED physicians preforming PS in conjunction with self-reported adverse events. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding bedside setup of airway equipment, and prevalence of self-reported adverse events. The primary outcome was the quantification of variability among ED physicians with respect to the above listed aspects of PS. Data was presented with simple descriptive statistics. Results: 278 ED physicians responded to our survey (response rate 20.9%). Respondents were primarily academic (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). The ED area in which PS was carried out varied; bedside (30.5%), procedure room (37.1%), resuscitation area (31.2%). The basic equipment set utilized appears to be a bag valve mask, suction, and an oral airway. These 3 items were present 95.4%, 95.9%, and 86.3% of the time respectively. The preparation of other items such as capnography and difficult airway equipment is highly variable and appears to be physician specific rather than clinical situation specific. The most common physician self-reported adverse events associated with PS appear to be hypoxia (Spo2<90%), hypotension (sBP<90), and prolonged sedation which occurred in 10.7%, 8.3%, and 8.1% of PS performed. Conclusion: There appears to be significant practice variability with respect to the clinical setting as well as the equipment ED physicians prefer when administering PS. Given that causal relationships cannot be inferred between airway/monitoring equipment preferences and adverse events, future studies should be targeted at identifying optimal bedside set ups which minimize adverse events.

Introduction: Laceration is common in children presenting to the emergency department (ED). They are often uncooperative related to pain and distressed during repair. Currently, there are wide variations regarding sedation and analgesia practices when sutures are required. There is a growing interest in the intranasal (IN) route for procedural sedation and pain control because of its effectiveness potential and ease of administration. Few studies have evaluated IN ketamine for procedural sedation in children with reported doses ranging from 3 to 9 mg/kg. The objective is to evaluate the optimal IN ketamine dose for effective and safe procedural sedation for laceration repair in children aged 1 to 12 years. Methods: A dose escalation clinical trial with an initial dose of 3 mg/kg of IN ketamine up to a maximum dose of 9 mg/kg in children 1 to 12 years old, using a 3+3 trial design. For each tested dose, 3 patients are enrolled. Escalation to the next dose is permitted if sedation is unsuccessful in at least one patient without serious adverse event (SAE). Regression to prior dose is warranted in the occurrence of two or more SEAs. This process is repeated until effective sedation for 6 patients at two consecutive doses is achieved with a maximum of 1 SAE or if regression occurs. The primary outcome is the optimal dose for successful procedural sedation as per the PERC/PECARN consensus criteria. Secondary outcome, namely, pain and anxiety levels, parent, patient and provider satisfaction, recovery time, length of stay in the ED, side effects and adverse event are recorded. Results: Nine patients have been recruited from March to December 2017 with median age of 2.9 years-old and with laceration length of 2 to 5 cm and with facial involvement in 55% of cases, respectively. Sedation was successful in 1/3, 1/3 and 3/3 of patients at doses of 3, 4, 5 mg/kg respectively, without any SAE. Median time from ketamine administration to return to baseline status and discharge were 35 and 98 min, respectively. We expect to complete patient recruitment in March 2018. Conclusion: The results from our trial is a groundwork for future dose-finding study. Pending study completion, a multicentric dose validation trial, is set up to further validate the optimal dose from dosINK1 trial. IN ketamine has the potential to improve the field of procedural sedation for children by introducing an effective IN agent with respiratory stability but without the need for an IV line insertion not otherwise needed.

Introduction: Emergency department (ED) physicians strive to provide analgesia, amnesia and sedation for patients when performing painful procedures through the use of procedural sedation (PS). Examination of the literature suggests that the application of PS appears to be variable with institutional influences and clinician disagreement on pharmacology, airway management, and monitoring. The primary goal of this research project was to describe the variability of practice with respect to pharmacologic choices and clinical applications of PS among Canadian ED physicians. Methods: An electronic survey was distributed through the Canadian Association of Emergency Physicians (CAEP). Practicing physician members of CAEP were invited to complete the survey. The 20 question survey encompassed various aspects of PS including physician choices regarding PS indications and pharmacology. The primary outcome was the quantification of practice variability among ED physicians with respect to the above listed aspects of PS. The data was presented with simple descriptive statistics. Results: To date, 278 ED physicians responded to our survey (response rate 20.3%). Respondents were primarily academic hospital (53.2%) or community hospital based (38.2%). With emergency medicine training as: CCFP-EM (55.2%), FRCPC (30.1%), and CCFP (9.0%). There was relative agreement on the following interventions requiring PS: 98.4% applied PS for electrical cardioversion and 98.1% for brief (<10 mins) orthopedic manipulations. However, only 36.3% utilized PS for burn debridement in the ED. PS was utilized less frequently (78.1%) for prolonged (>10mins) orthopedic manipulations than brief manipulations. For all procedures aggregated, in hemodynamically stable patients with an American Society of Anesthesiology (ASA) score of 1, ED physicians utilized propofol 76.3% of the time. Additional agents were utilized at the following rates: fentanyl-propofol (7.6%), ketamine (7.6%), and fentanyl (4%). This inclination towards propofol alone appears to be consistent across modality of ER training, type of ER setting (rural vs academic), and volume of PS performed. Conclusion: This study demonstrates that Canadian ED physicians have a clear preference for propofol as a first line pharmacologic agent when administering PS in hemodynamically stable, ASA1 patients. Conversely, there appears to be more variation amongst ED physicians with respect to second line pharmaceutical choices for PS.

Introduction: The use of procedural sedation and analgesia (PSA) for the performance of Emergency Department (ED) procedures has been reported to be safe and effective. However, few studies have evaluated the safety of PSA in the elderly, with conflicting results. Our primary objective was to determine if elderly patients undergoing PSA for the management of an orthopedic injury had an increased risk of adverse events (AEs) during the procedure. Methods: This retrospective review of prospectively recorded data between 2006 and 2016 included patients aged ≥16 years undergoing PSA at a single institution to facilitate treatment of a fracture or dislocation. Patients were separated into 3 age groups for analysis: young (18-40), middle-aged (41-64) and elderly (≥65). Elderly patients were divided into 3 subgroups. The primary AEs studied include hypoxia (SpO2<90 %) and hypotension (systolic blood pressure <100 mmHg, or >15% reduction from baseline if initial <100 mmHg). Logistic regression (LR) models tested for associations between age and outcome measurements. Effect sizes were described as odds ratios (OR) and 95% confidence intervals. Results: 4171 patients were studied, including 1125 patients ≥65 years of age. More than 90% of the time, propofol was used as a single agent sedative. Fentanyl was given as an analgesic adjunct in 88% of patients. Medication dosing declined as patients aged. In the young group, the average total propofol dose was 2.34 mg/kg compared to 1.42 mg/kg in the elderly (≥85 years subgroup: 1.07 mg/kg). Despite this, hypoxia was more likely to occur in elderly patients (2.3%) compared to younger patients (0.4%). LR models demonstrated that hypoxia was more likely to occur in: the elderly [OR 4.29 (1.58,11.70)], patients with an ASA classification score of 3 or higher [OR 4.71 (1.89,11.70)], and higher dosing of fentanyl in the elderly [OR 2.35 (1.21,4.57)]. Oral or nasal airway, assisted ventilation, and suctioning were required in less than 1% of all patients. Endotracheal intubation was never required. Hypotension was more likely in elderly patients (11.6%) than younger patients (8.3%). Conclusion: When performing PSA, clinicians should be aware of the increased risk of AEs in the elderly, particularly hypoxia, and modify selection, dosing, and administration of the PSA medication(s) appropriately. Future study should examine the intermediate and long-term outcomes of elderly patients following ED PSA.

Introduction: Bier block (BB) regional intravenous anesthesia is a safe and effective alternative to procedural sedation for analgesia during forearm fracture reductions, yet BB remains infrequently utilized in the Pediatric Emergency Department (PED). No standardized methods of BB training have previously been described. The objectives of this study were to evaluate comfort and level of experience with BB in the PED, and to determine if a multimodal instructional course increases these from baseline and translates to increased utilization of this technique. Methods: A novel interdisciplinary simulation and web-based training course was developed to teach the use of BB for forearm fracture reduction at a tertiary PED. Participants were surveyed pre/post training, and at 2- and 6-months regarding their comfort with and willingness to use BB. In parallel, we prospectively assessed the clinical utilization of BB in the PED during the 24-month period immediately following course completion. Results: Course participation included 38 members of the PED (N = 26 physicians, 12 nurses), and survey response rate was 100% at all time points. Respondents reported that course participation increased both their comfort (10% pre vs. 89% post-training, p<0.001) and willingness (51% pre vs. 95% post-training, p<0.001) to use BB for forearm fracture reduction, an effect that was sustained at 6-months following course completion (66% and 92%, respectively, p<0.001 for both). Before course attendance, only 6% of respondents indicated that they had ever used BB in a PED setting, and all participants indicated that the course addressed their learning objectives. In clinical practice, there were no BB performed prior to course administration. We observed a consistent and sustained increase in the clinical utilization of BB, with 39% of all PED forearm reductions performed using BB at 24-months post-course completion (114 BB, 17 unique physicians). Conclusion: A combined simulation and web-based training course increased comfort and willingness to use BB and was associated with increased utilization of this technique for forearm fracture reduction in the PED.