Drug Choice for Procedural Sedation: Propofol vs. Ketamine

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Author: Randy Kring, MSIV
Tufts University School of Medicine

Procedural sedation is frequently performed in the emergency department, whether it is for electrical cardioversion, closed joint reduction or abscess incision and drainage. Although the focus in these cases is often on the procedure, smart preparation for procedural sedation and an understanding of the different strategies that can be used is vitally important.

The goal of procedural sedation is to provide moderate sedation and analgesia while preserving the patient’s protective airway reflexes, adequate ventilation and cardiovascular function. Relative contraindications for procedural sedation may include advanced age, significant medical comorbidities such as CHF or COPD or signs of a difficult airway.[1] Recent food intake is not a contraindication for procedural sedation, but aspiration risk should be assessed and minimized whenever possible.[2] Many drugs can be used for procedural sedation, including midazolam, etomidate, propofol and ketamine. Which drug is “the best?”

Propofol, a sedative and amnestic, has onset in about 40 seconds and duration of action of about six minutes. Common side effects include pain at the injection site, hypotension and respiratory depression.[3] Ketamine, a dissociative anesthetic that provides sedation, amnesia and analgesia, has onset in about 30 seconds and duration of action of about 10 to 20 minutes. Common side effects include agitation on emergence, nausea and (rarely) tachycardia and hypertension.[4]

Clinical Pearl: Procalcitonin and Lower Respiratory Tract Infections

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Author: Jordan Kaylor, MD PGY4
Northwestern/McGaw Medical Center

Procalcitonin (PCT) is a serum biomarker that, when paired with clinical judgment, may help guide management of lower respiratory tract infections (LRTIs) in the emergency department (ED). Procalcitonin levels can help clinicians distinguish between bacterial and viral infections and might subsequently guide decisions to initiate or discontinue antibiotics. Procalcitonin is a prohormone of calcitonin. It is an acute-phase reactant synthesized in many tissues and released in response to cytokines such as interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF)-α.1 Normal serum concentrations are <0.05ng/mL, but in bacterial infections, PCT increases to detectable levels within three to four hours (earlier than ESR or CRP).[1] Elevations are not seen in noninfectious inflammatory conditions or viral infections, but are possible in Addisonian crises, malaria, severe fungal infections and medullary thyroid carcinoma.[1] In viral infections, interferon (INF)-ɣ probably decreases PCT release, leading to lower or undetectable serum levels.[2]

Exploring an interest in Wilderness Medicine

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This post was peer reviewed.
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Author: Josh Symes, MD
EM PGY-1
University of Mississippi Medical Center

Wilderness Medicine affords the opportunity to combine passion for the outdoors with passion for medicine. Many people pursue wilderness medicine to be better equipped to use their medical training and expertise in medical situations they may encounter outside the hospital such as fishing, backpacking, mountain biking, etc. Others apply the training in lower resource settings on medical service trips abroad. Some make it a significant part of their career in medicine. It also provides an excellent teaching platform (ex. making the physiology of altitude more interesting). WM can provide opportunities for team building exercise through scenario-based training in medical school or residency. Some medical schools and residency programs have wilderness medicine built into the curriculum, but many do not. This blog entry aims to provide a primer of ways to explore an interest in wilderness medicine.

Summer and Acute Otitis Externa

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Author: Christine Au
Medical Student- OMS-II
Western University of Health Sciences, College of Osteopathic Medicine of the Pacific
AAEM/RSA Social Media Committee




As summer is nearing an end, the days of pool parties and water sports has brought many cases of the much dreaded ear infection to emergency departments around the country. Otitis externa is known among most as “Swimmer’s Ear.” Acute otitis externa (AOE) is an inflammation of the external ear canal and is further explained as a cellulitis of the skin inside the external ear canal. In North America, 98% of the causes of AOE are bacterial, but viral and fungal sources have also been documented.[1] The most likely bacterial causes of AOE are Pseudomonas aeruginosa and Staph aureus.[1] According to Rosenfeld, the diagnosis is based on the rapid onset of disease; in most cases, the pain occurs within 48 hours from the time of exposure.[2] In addition, most patients experience itching, severe pain (otalgia), and in some cases, may complain of a feeling of “fullness” in the affected ear.[2] Some patients may also have pain upon jaw movement or even hearing loss.[2-3]

It’s a Privilege, Not a Burden

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Author: Jacob Stelter, MS4
Loyola University Chicago
Stritch School of Medicine
Originally Published: Common Sense November/December 2014

After years of battling things like prematurely adopted EMRs, government bureaucrats, clueless hospital administrators, greedy insurance companies, malignant tort lawyers, CMG profiteers, and "emergency" patients who don't need to see any doctor at all — much less an emergency physician — it is easy to become jaded and lose sight of our real value. That's why I chose to publish this editorial from a medical student. I hope it reminds you of the true worth of what you do, and how important you are. Stay strong! — Andy Walker, MD FAAEM, Editor Common Sense

I recently read an article in the Chicago Tribune entitled, “Expert’s New Career Prescription: Forget About Becoming a Doctor.”[1] In it author Dawn Turner Trice interviews the executive director of the Chicago Area Health and Medical Careers Program, Regnal Jones, who advises students not to pursue a career as a physician. He cites the cost of tuition, the many years of training, the long hours, and more medical graduates than residency spots — among other things — as reasons not to become a physician. I respect his opinion and have no doubt that some of his points are legitimate, especially regarding the cost of tuition and the fact that there are insufficient residency spots for graduating medical students. However, I respectfully disagree with much of what he says. At the end of her article Trice says, “You've heard Jones' position. Now tell me what you think.” Well, I did just that — sending her an email rebutting most of Jones' arguments. Now I want to explain to you why Jones is largely wrong, and present some of the positive aspects of being a physician.