UMEM Educational Pearls - By Prianka Kandhal

In this review of 4 RCTs, when compared with intranasal fentanyl, intranasal ketamine was non-inferior in its efficacy at providing analgesia for acute pain. In total, the studies included 276 participants, aged 3-17, who rated their pain moderate to severe. The patients were randomized to receive either IN ketamine (1-1.5 mg/kg) or IN fentanyl (1.5-2 ug/kg). Most patients had extremity injuries although some also had acute abdominal pain. All studies included patients who had received acetaminophen or ibuprofen prior to the interventions.
 
The reduction in pain at different time points, duration of pain control, and rates of requiring rescue analgesia were similar between the two groups. The risk of adverse events was higher in the ketamine group, however most adverse effects were very minor (nausea/vomiting, dizziness, unpleasant taste, and drowsiness were most frequent). The only serious adverse event (hypotension) was seen in the fentanyl group. Ketamine did have a slightly higher rate of associated sedation, although no patients became deeply sedated after receiving the ketamine and none required any intervention for sedation.
 
Take Home: Intranasal ketamine may be a good non-opioid pain medication to add to your toolkit. Dosing is 1-1.5 mg/kg intranasally. Although there may be an increased risk of adverse events, there are predominantly very minor.

 

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Category: Pediatrics

Title: Temporizing Measures for Button Battery Ingestions

Keywords: button battery, pediatrics, esophageal injuries (PubMed Search)

Posted: 9/4/2020 by Prianka Kandhal, MD
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Ingestion of a button battery is a can't-miss diagnosis with a very high risk for causing severe esophageal injury. There are about 3000 button battery ingestions per year, and this is increasing because electronics are becoming more and more prevalent.

Severe damage to the esophagus occurs within 2 hours. On your lateral view, the end with narrowing is the negative end, which triggers a hydrolysis reaction that results in an alkaline caustic injury and, ultimately, liquefactive necrosis.

Children can present with nonspecific symptoms and if the ingestion was not witnessed, they are at high risk for delays in diagnosis. Additionally, in the community setting, there can be further delays in definitive treatment (endoscopic removal) due to difficulty in calling teams in or transporting to other facilities.

Anfang et al. looked into ways to mitigate damage to esophageal tissue. They did an in vitro study on porcine esophageal tissue, measuring the pH with different substances applied. They tried apple juice, orange juice, gatorade, powerade, pure honey, pure maple syrup, and carafate. They then repeated the study in vivo on piglets with button batteries left in the esophagus and ultimately did gross and histological examination of the esophageal tissue.

Honey and carafate demonstrated protective effects both in vitro and in vivo. They neutralized pH changes, decreased full-thickness esophageal injury, and decreased outward extension of injury into deep muscle.

Take Home Point: If a child is found to have a button battery in the esophagus, while definitive management is still emergent endoscopic removal, early and frequent ingestion of honey (outside of the hospital) and Carafate (in the hospital) may help reduce the damage done to the tissue in the interim. The authors recommend 10ml every 10 minutes.

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