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Comment s Vomiting is a well-known side-effect of procedural sedation using ketamine for painful procedures in the ED. Ondansetron is a widely available, regularly prescribed antiemetic in paediatric medicine.

Two studies have shown a beneficial effect of ondansetron in paediatric procedural sedation with intravenous ketamine.

Langston et al demonstrated that ondansetron significantly reduces emesis in children undergoing intravenous ketamine procedural sedation in children of all ages, with a NNT of 8 in children older than 5 years, although this subanalysis has a wide confidence interval.

Bhatt et al have shown in a multicentre prospective cohort study that use of antiemetic significantly reduces the rate of vomiting in ketamine procedural sedation.

This study also showed that the rate of emesis during ketamine procedural sedation is higher in children who have received preprocedural opioids.

Two prospective randomised controlled studies showed no significant difference between intramuscular ketamine alone or ketamine with antiemetic, although both studies have significant limitations.

Lee had a statistically significantly higher mean age of children in the ketamine with ondansetron group older children are more likely to vomit whilst undergoing ketamine sedation than in the ketamine alone group whilst Lee only included children younger than 5, an age group in whom vomiting is less common and are less likely to benefit from antiemetic.

Editor Comment CF Clinical Bottom Line Ondansetron should be considered when using intravenous ketamine for procedural sedation in the ED, especially in older children or those who have received preprocedural opioids.

Only children 8. Kong V. No subsequent readmissions, morbidity or mortality. Mean length of hospital stay 1.

Retrospective case note review so not all required data may be available. Single centre study so results may not be generalisable.

Small number of patients analysed with no statistical analysis. Zhang, M. Patients were categorised as largest air pocket of pneumothorax measuring more than 35mm or 35mm or less from the pleura to the mediastinum.

Management was either immediate tube thoracostomy or observation Failure of observation defined as a need for delayed tube thoracostomy or secondary intervention.

The clinical course of penetrating chest injury may vary. The decision to place an intercostal drain was left to individual clinician discretion.

Retrospective, single centre study. Walker, S. Retrospective, observational study. Mean duration to intervention was 2. Low rate of penetrating chest wall injury.

Variation in initial imaging modality. High risk, unwell patients were likely under-represented in the conservative treatment arm.

Inclusion criteria required a 3 day hospital stay or admittance to the high dependency unit; this likely provides bias against conservatively managed patients who are more likely to be discharged early.

Hence the overall rate of effective conservative treatment is likely greater than observed. Patients receiving immediate intervention likely to have different baseline characteristics to the conservative arm.

Median hospital length of stay. Drain re-sited 4. Saricam, M. Single centre, retrospective, observational study.

To compare treatment approaches conservative v chest tube in patients of varying traumatic pneumothorax size. One patient developed recurrent pneumothorax at 10 days.

Two patients developed recurrent pneumothorax at 10 days. Retrospective observational study so some data may be missing.

Small patient numbers. No statistical analysis. Mahmood, I. Retrospective trauma database review. Requirement for delayed tube thoracostomy.

Retrospective study. Statistical analysis is not on an intention to treat basis- patients who failed initial observation were included in the tube thoracostomy group.

Since these reviews, further evidence has been published, as presented in this BET. Despite the heterogeneity of study design, in general conservatively managed patients were observed for signs of clinical or radiological deterioration during admission to hospital for at least 24 hours.

Clinical parameters of deterioration include: respiratory distress, haemodynamic instability and reduced level of consciousness. Radiological deterioration includes: increasing size of pneumothorax, tension pneumothorax, haemothorax and pleural effusion.

Several patients underwent repeat chest x-ray during admission. If there were no signs of clinical or radiological deterioration patients were discharged with follow up.

Saricam et al. No other studies reported further morbidity, mortality or complications in conservatively managed patients. Length of hospital stay was at worst no longer in the conservatively managed patients than those undergoing tube thoracostomy, with multiple studies demonstrating a reduced length of stay.

Patients with a large pneumothorax were consistently at an increased risk of failing conservative treatment. Four papers provided data whereby a specific size of pneumothorax could be deemed safe to observe.

Kong et al. All patients should be observed for at least 24 hours post-injury for signs of clinical or radiological deterioration.

Should these occur, chest drain insertion should be considered. Patients discharged without intervention should undergo outpatient follow up.

References Hegarty, M. A conservative approach to penetrating injuries of the chest. Experience with successive cases.

Injury ; pp. Knottenbelt, J. Traumatic pneumothorax: a scheme for rapid patient turnover. An objective method to measure and manage occult pneumothorax.

CT detection of occult pneumothorax in multiple trauma patients. Journal of Emergency Medicine ; pp. Traumatic pneumothorax: is a chest drain always necessary?

Emergency Medicine Journal. Validity of CT classification on management of occult pneumothorax. American Journal of Roentgenology ; pp.

Ondansetron is a widely available, regularly prescribed antiemetic in paediatric medicine. Two studies have shown a beneficial effect of ondansetron in paediatric procedural sedation with intravenous ketamine.

Langston et al demonstrated that ondansetron significantly reduces emesis in children undergoing intravenous ketamine procedural sedation in children of all ages, with a NNT of 8 in children older than 5 years, although this subanalysis has a wide confidence interval.

Bhatt et al have shown in a multicentre prospective cohort study that use of antiemetic significantly reduces the rate of vomiting in ketamine procedural sedation.

This study also showed that the rate of emesis during ketamine procedural sedation is higher in children who have received preprocedural opioids.

Two prospective randomised controlled studies showed no significant difference between intramuscular ketamine alone or ketamine with antiemetic, although both studies have significant limitations.

Lee had a statistically significantly higher mean age of children in the ketamine with ondansetron group older children are more likely to vomit whilst undergoing ketamine sedation than in the ketamine alone group whilst Lee only included children younger than 5, an age group in whom vomiting is less common and are less likely to benefit from antiemetic.

Editor Comment CF Clinical Bottom Line Ondansetron should be considered when using intravenous ketamine for procedural sedation in the ED, especially in older children or those who have received preprocedural opioids.

Only children 8. Vomiting significantly lower in Ondansetron group 4. Variation in initial imaging modality. High risk, unwell patients were likely under-represented in the conservative treatment arm.

Inclusion criteria required a 3 day hospital stay or admittance to the high dependency unit; this likely provides bias against conservatively managed patients who are more likely to be discharged early.

Hence the overall rate of effective conservative treatment is likely greater than observed. Patients receiving immediate intervention likely to have different baseline characteristics to the conservative arm.

Median hospital length of stay. Drain re-sited 4. Saricam, M. Single centre, retrospective, observational study. To compare treatment approaches conservative v chest tube in patients of varying traumatic pneumothorax size.

One patient developed recurrent pneumothorax at 10 days. Two patients developed recurrent pneumothorax at 10 days. Retrospective observational study so some data may be missing.

Small patient numbers. No statistical analysis. Mahmood, I. Retrospective trauma database review. Requirement for delayed tube thoracostomy.

Retrospective study. Statistical analysis is not on an intention to treat basis- patients who failed initial observation were included in the tube thoracostomy group.

Since these reviews, further evidence has been published, as presented in this BET. Despite the heterogeneity of study design, in general conservatively managed patients were observed for signs of clinical or radiological deterioration during admission to hospital for at least 24 hours.

Clinical parameters of deterioration include: respiratory distress, haemodynamic instability and reduced level of consciousness. Radiological deterioration includes: increasing size of pneumothorax, tension pneumothorax, haemothorax and pleural effusion.

Several patients underwent repeat chest x-ray during admission. If there were no signs of clinical or radiological deterioration patients were discharged with follow up.

Saricam et al. No other studies reported further morbidity, mortality or complications in conservatively managed patients.

Length of hospital stay was at worst no longer in the conservatively managed patients than those undergoing tube thoracostomy, with multiple studies demonstrating a reduced length of stay.

Patients with a large pneumothorax were consistently at an increased risk of failing conservative treatment. Four papers provided data whereby a specific size of pneumothorax could be deemed safe to observe.

Kong et al. All patients should be observed for at least 24 hours post-injury for signs of clinical or radiological deterioration.

Should these occur, chest drain insertion should be considered. Patients discharged without intervention should undergo outpatient follow up.

References Hegarty, M. A conservative approach to penetrating injuries of the chest. Experience with successive cases. Injury ; pp. Knottenbelt, J.

Traumatic pneumothorax: a scheme for rapid patient turnover. An objective method to measure and manage occult pneumothorax.

CT detection of occult pneumothorax in multiple trauma patients. Journal of Emergency Medicine ; pp. Traumatic pneumothorax: is a chest drain always necessary?

Emergency Medicine Journal. Validity of CT classification on management of occult pneumothorax. American Journal of Roentgenology ; pp.

Brasel, K. Treatment of Occult Pneumothoraces from Blunt Trauma. Barrios, C. Successful management of occult pneumothorax without tube thoracostomy despite positive pressure ventilation.

American Journal of Surgery ; pp. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation? Blunt traumatic occult pneumothorax: is observation safe?

The Journal of Trauma. Kong, V. The selective conservative management of small traumatic pneumothoraces following stab injuries is safe: experience from a high-volume trauma in South Africa.

European Journal of Emergency Surgery ; pp. Occult pneumothorax in blunt trauma: is there a need for tube thoracostomy?

European Journal of Trauma and Emergency Surgery ; pp. Eddine, S. Observing pneumothoraces: The millimeter rule is safe for both blunt and penetrating chest trauma.

Journal of Trauma and Acute Care Surgery ; pp.

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