The edition · Emergency & Critical Care
Intranasal ketamine matches the needle for acute trauma pain
A 1,194-patient trial finds no clinically important difference between intranasal and subcutaneous ketamine, magnesium added to paracetamol helps headache statistically but marginally, and a protocolised early mobilisation programme did not improve function at ICU discharge or a year later.
The edition in brief
A double-blind, double-dummy trial randomised 1,194 adults with acute musculoskeletal trauma to 20 mg ketamine either subcutaneously or intranasally. Pain fell by 3.70 points on the numerical rating scale with the subcutaneous route and 4.42 with intranasal — a difference of 0.72 (95% CI -0.95 to -0.48) that is statistically real but below the 1.3-point threshold for clinical importance, at every time point. Minor adverse events were commoner with the subcutaneous route. In practice the routes are interchangeable, which makes needle-free analgesia a reasonable default. A second trial from the same group randomised 1,028 adults with acute non-traumatic headache, all given oral paracetamol, to 2 g intravenous magnesium sulphate or placebo. Treatment success at 30 minutes was 78.9% versus 65.1% (difference 13.8%, 95% CI 8 to 19), rescue analgesia 7.1% versus 15.3%, adverse events 15.4% versus 11.1%. Every pain-score difference again sat below the clinical importance threshold. EVER randomised 169 mechanically ventilated patients with sepsis or respiratory failure to a structured six-step early mobilisation programme or usual care. The programme was delivered — mobilisation started at 30 rather than 46 hours, with 11 sessions instead of 4 — but functional status at ICU discharge was unchanged (23.6 versus 22.2, p=0.44), as were all 12-month outcomes. A meta-analysis of 12 non-randomised studies found phenobarbital-based pathways for alcohol withdrawal shortened ICU stay by 0.60 days without changing intubation, at very low certainty. ACEP has approved new two-part consensus guidelines on unscheduled procedural sedation. Today's pearl: atropinisation in organophosphate poisoning has defined endpoints — use them.
Intranasal ketamine works as well as the needle for acute trauma pain
Give intranasal ketamine rather than waiting for access in acute musculoskeletal trauma — 20 mg intranasal relieved pain as well as 20 mg subcutaneous, with fewer minor adverse events.
Magnesium for acute headache: more patients respond, but not by much
Add 2 g intravenous magnesium to simple analgesia for an acute headache that is not settling — it roughly halves the need for rescue analgesia, though the average pain score barely shifts.
EVER: the early mobilisation programme was delivered, and it changed nothing
Keep mobilising ventilated patients early because it is safe and humane, but do not expect a more intensive protocol to improve functional recovery at discharge or at a year.
Atropinisation has endpoints — stop titrating to pupils
Titrate atropine in organophosphate poisoning to a clear chest, dry axillae, systolic BP above 80 and heart rate above 80, doubling the dose until you get there — never to pupil size.
Phenobarbital for alcohol withdrawal: the pathway may matter more than the drug
Phenobarbital-based pathways for alcohol withdrawal shorten ICU stay by about half a day and do not clearly reduce intubation — and only front-loaded, protocolised versions show promise.
ACEP approves new consensus guidelines on unscheduled procedural sedation
New ACEP guidelines on unscheduled procedural sedation are out in two parts — read them in full, and meanwhile audit your department's credentialling, monitoring and rescue arrangements.
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