IM Ketamine for Prehospital Sedation of the Agitated Patient

March 2006

IM Ketamine for Prehospital Sedation of the Agitated Patient

EMJClub.com


Vignette

You can the waiting room on a very busy night and notice a patient with the chief complaint of cough and shortness of breath.  At the height of flu season you are appropriately concerned that the longer this patient waits in triage, the more he is going to spread that bothersome virus and expose other already debilitated people.  Therefore, you decide to be proactive by providing the patient with a mask, secretly hoping the patient isn’t really harboring the Bird Fly.  As you hand the patient his mask, you notice he looks quite ill.  The patient is coughing and febrile with an increased respiratory effort.  you call the charge nurse and immediately find the patient a room.

Your initial physical exam suggests pneumonia so you order antibiotics and a confirmatory chest X-ray, in addition to ancillary tests and therapies.  Azithromycin and ceftriaxone are initiated within 3 hours of the patient’s arrival and after a few hours delay in obtaining a chest X-ray, your diagnosis is confirmed.  You congratulate yourself on a fine job:  you have initiated disease-appropriate antibiotics less than four hours from presentation.  The patient is admitted and makes a full recovery.

You are even more proud of yourself when the following week you receive a box of chocolates from the patient who wanted to thank you for your wonderful care and for taking the time to see him in the waiting room.  Your bubble is quickly  burst as you receive an email from the community acquired pneumonia (CAP) committee stating that you failed to provide the standard of care requested by your hospital because you did not obtain blood cultures prior to antibiotic therapy in an admitted patient with CAP.  You think, “Blood cultures?”  Who needs blood cultures?  Does ti really change how we treat these patients?”  You decide the hospital’s policies are lacking in validity and look for evidence in the literature supporting the utility of blood cultures in CAP


PICO Question

Population: Adults presenting to ED with suspected community acquired pneumonia

Intervention: Blood cultures

Comparison: No blood cultures

Outcome: Antimicrobial therapy change due to blood culture results, mortality, length-of-stay in hospital

Search Strategy
Recognizing that the Infectious Diseases Society of America (IDSA) Guidelines have existed for many years, you believe that a large, evolving body of literature probably exists to evaluate the utility of cultures in CAP.  Therefore, you first search Emergency Medicine Abstracts, a pre-filtered database dating back to 1997.  Utilizing the search term “pneumonia AND cultures”, you obtain 77 citations.  Utilizing OVID (1996 to present) you enter the search term “pneumonia AND blood culture*” which yields 266 articles, one of which is the November 2005 publication below that is too new to have appeared in the pre-filtered database of EM Abstracts.  Additionally, you pull the most updated version of the IDSA Guidelines (Clin Infec Disease 2003; 37: 1405-1433) and scan their recommendations for supporting references. Unfortunately, their recommendations are not associated with references, but rather a bibliography consisting of 235 citations.  You select a handful of the articles to briefly review, scan their respective abstracts and associate editorials and finally select the four articles noted below to review in detail.


Years

First Years:  Clinical Utility of Blood Cultures in Adult Patients with Community-Acquired Pneumonia without Defined Underlying Risks.  Chest 1995; 108: 932-936

Second Years:  ANSWER KEY Chest 1999: 116: 1278-1281

Third Years:  ANSWER KEY Chest 2003; 123: 1142-1150

Fourth Years:ANSWER KEY Annals EM 2005; 46: 393-400

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