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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com


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domingo, 18 de noviembre de 2018

Severe Hyponatremia

PulmCCM - November 17, 2018
"Severe hyponatremia (often defined as a serum sodium < 120 mEq/L) occurs most often in people with pituitary or lung tumors, those taking antipsychotic or other neuroleptic drugs, heavy beer drinkers, or the elderly. Usually sodium levels decline slowly over weeks or months prior to detection, allowing time for the brain to compensate, with only minor neurologic symptoms.
Sodium levels will often return to normal just as slowly, with minimal intervention by physicians (change in drug therapy, fluid restriction, etc). But new evidence shows that when patients with hyponatremia get admitted to the hospital, their impatient treatment teams often correct sodium levels too quickly, increasing the risk for dangerous complications..."

sábado, 17 de noviembre de 2018


Emergency Medicine PharmD - May 4, 2015 - By Matthew DeLaney
..."Tramadol has been marketed as a novel analgesic that offers pain relief comparable to opioids without the associated risks of abuse or dependency. As its use has increased, there is emerging data to suggest that tramadol is not a medication that should be routinely used in the emergency department. From questionable efficacy, risk of dependency/abuse, to a somewhat unique risk of complications, there are three major reasons why providers should be careful when using tramadol...
Despite its widespread use, there are significant issues that providers should consider before using tramadol. In terms of efficacy tramadol has not been shown to consistently outperform other available analgesics. In addition, tramadol has a set of potential side effects that make it a less than ideal first line analgesics. Finally tramadol does not appear to be a “safe opioid” as there seem to be significant potential for abuse, dependency, and withdrawal."

jueves, 15 de noviembre de 2018

Cricoid Pressure in Airway Management:

R.E.B.E.L.EM - November 15, 2018 - By Anand Swaminathan
..."Potential to Impact Current Practice: Cricoid pressure should not routinely be provided to patients undergoing intubation.
Bottom Line: Occlusion of the esophagus by cricoid pressure appears to be a myth based on MRI and US studies. Previous literature demonstrates that cricoid pressure gives inferior views and no high-quality literature has shown decreased aspiration with application of cricoid pressure.
All of this in conjunction with the numbers seen in this study tells us that pulmonary aspiration is uncommon in the OR setting and isn’t reduced by the application of cricoid pressure. While an ED based study would be nice to have, the current evidence tells us that application of cricoid pressure is unlikely to benefit our patients but is likely to make our intubation more difficult..."

Intracranial Hemorrhage (ECG)

emDocs - November 14, 2018 - Author: Tannenbaum LL
Edited by: Santistevan J; Singh M and Long B
"Take home points:
  • In patients with intracranial hemorrhage, hypertension and bradycardia can be signs that herniation is occurring.
  • There are many nonspecific ECG changes seen in patients with intracranial hemorrhage including ST changes, QT prolongation, and T-wave inversions.
  • Occasionally these changes can mimic acute coronary syndromes including STEMI and can lead to misdiagnosis, unnecessary thrombolytics, or PCI.
  • Sometimes, it isn’t the heart"

martes, 13 de noviembre de 2018

Brain Injury after Cardiac Arrest

Maryland CC Project - By Jim Lantry - November 12, 2018
"Please welcome back an old friend of Baltimore, Karen G. Hirsch, MD. Dr. Hirsch is an Assistant Professor of Neurology and the Director of Neurocritical Care at the Stanford University Medical Center. She is also one of the guru’s and experts in the field of neuroprognostication after cardiac arrest leading to a multitude of publications and numerous grants. Today we are exceedingly fortunate to have her grace the halls of The University of Maryland to give us a crash course on what we SHOULD be doing for our cardiac arrest patients. I assure you, this is a lecture all of us need to hear!"
Resultado de imagen de vimeo

lunes, 12 de noviembre de 2018

Whole blood in the trauma bay

St. Emlyn´s - By Zaf Qasim - November 9, 2018
"One thing is clear from the military and civilian literature – hemorrhage kills1,2. Overall, 40-50,000 deaths per year in the US are preventable with appropriate hemorrhage control and resuscitation. The demographic of these victims is primarily young, healthy individuals who would otherwise have had the chance to live a productive life.
Resuscitation should address the components responsible for hemorrhagic shock – blood loss and systemic injury – while mitigating hemodilution. There has been a concerted push away from using clear fluids for initial resuscitation, with recent evidence pointing to the mortality benefit of using balanced ratios of packed red cells, plasma, and platelets in massive transfusion3.
The aim of balancing components is to approximate reconstituted whole blood – so why not just give whole blood?..."

Ways to Solve ED Boarding

Emergency Physicians Monthly
Emergency Physicians Monthly - By Shah S and Esbenshade A - October 31, 2018
"Strategies to increase efficiency and involvement.
In 2011, nine out of 10 hospitals reported boarding patients in the emergency department while they awaited inpatient beds.
The Joint Commission has since made boarding part of its survey process because it’s a patient care and safety issue. But the negative effects don’t stop at safety and clinical outcomes. There are also the negative downstream effects of boarding, including the inability to treat newly arriving patients, longer cycle times for existing ED patients and poor perception of quality and confidentiality by boarded patients.
With the stakes so high, can you afford to not address this issue? Here are seven ways to solve the ED boarding challenge..."

Angiotensin–Neprilysin Inhibition in ADHF

Velazquez E et al. NEJM - November 11, 2018 - DOI: 10.1056/NEJMoa1812851
Among patients with heart failure with reduced ejection fraction who were hospitalized for acute decompensated heart failure, the initiation of sacubitril–valsartan therapy led to a greater reduction in the NT-proBNP concentration than enalapril therapy. Rates of worsening renal function, hyperkalemia, symptomatic hypotension, and angioedema did not differ significantly between the two groups. (Funded by Novartis; PIONEER-HF ClinicalTrials.gov number, NCT02554890.)"


Urgencias y Emergencias
Urgencias y Emergencias - By Elena Plaza Moreno - November 6, 2018
"Acaba de publicarse la actualización 2018 de AHA de ACLS y PALS (soporte vital avanzado de adultos y pediatría) de AHA.Esto es debido a que desde el 2015, ILCOR comenzó un proceso continuo de revisión de la evidencia. Esto se traduce en la práctica en que las recomendaciones ya no se realizan cada 5 años, sino que se hacen actualizaciones continúas.
El año pasado se actualizaron las recomendaciones sobre Soporte Vital Básico tanto de adultos como de pediatría. Y ayer se actualizaron las recomendaciones sobre Soporte Vital cardiovascular avanzado tanto de adultos como de pediatría.
Os dejo con mi propia traducción del documento de Highlights de los cambios (podéis ver el original en inglés al final de esta entrada). Los cambios ya se han introducido en la web de la AHA, en la parte de las guías integradas (está en inglés): https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/
Y podéis ver y descargar el documento completo publicado en Circulation para adultos aquí y para pediatría aquí."

miércoles, 7 de noviembre de 2018

Lung Abscess

emDocs - November 7, 2018 - Author: Ramzy M - Edited by: Koyfman A and Long B
  • Obtain sputum cultures in hospitalized or septic patients to better focus antibiotic therapy.
  • Clindamycin is the first line antibiotic of choice; transition from IV to PO when appropriate.
  • Blood cultures are rarely positive in anaerobic lung abscesses.
  • Consider admission and IV antibiotics rather than discharging patients with poor outpatient follow-up or those who may be non-compliant with antibiotics."

Epinephrine in out of hospital cardiac arrest

First 10EM - Justin Morgenstern - November 6, 2018
I am concerned, after reviewing all this data, that we are harming our patients with the routine use of epinephrine in cardiac arrest. I would remove it from the algorithms, but recognize that there are still many questions, and that there may be individual patient circumstances in which a bolus of epinephrine might make sense."

Blunt cerebrovascular injury

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine logo
Tor Brommeland et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2018; 26:90 - https://doi.org/10.1186/s13049-018-0559-1
"Blunt cerebrovascular injury (BCVI) is a non-penetrating injury to the carotid and/or vertebral artery that may cause stroke in trauma patients. Historically BCVI has been considered rare but more recent publications indicate an overall incidence of 1–2% in the in-hospital trauma population and as high as 9% in patients with severe head injury. The indications for screening, treatment and follow-up of these patients have been controversial for years with few clear recommendations. In an attempt to provide a clinically oriented guideline for the handling of BCVI patients a working committee was created. The current guideline is the end result of this committees work. It is based on a systematic literature search and critical review of all available publications in addition to a standardized consensus process. We recommend using the expanded Denver screening criteria and CT angiography (CTA) for the detection of BCVI. Early antithrombotic treatment should be commenced as soon as considered safe and continued for at least 3 months. A CTA at 7 days to confirm or discard the diagnosis as well as a final imaging control at 3 months should be performed."

Troponinas cardiacas en el IAM en emergencias

Colaboración entre la Sociedad Española de Cardiología, la Sociedad Española de Medicina de Urgencias y Emergencias y la SEQC-ML
SEQC - 18/10/2018
"Representada por los Dres. Jordi Ordóñez y Eva Guillén, la SEQCML ha participado en la elaboración de un documento de consenso sobre la utilización de la troponina cardiaca para el diagnóstico del infarto agudo de miocardio en Urgencias, publicado recientemente en la Revista Emergencias. Dicha participación se ha desarrollado en colaboración con la Sociedad Española de Cardiología (SEC) y la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES)...
Además, la SEC ha publicado una completa infografía en la que se muestran las recomendaciones de uso y las conclusiones alcanzadas en el documento de consenso..."

lunes, 5 de noviembre de 2018

Procalcitonin in COPD exacerbations

PulmCCM - November 4, 2018
..." Most of the small studies testing procalcitonin-driven algorithms have shown the method to be generally safe and effective at reducing antibiotic use. But a new study suggests that in patients with COPD exacerbations admitted to the ICU, withholding or stopping antibiotics based on PCT levels could be harmful...
Procalcitonin shouldn't be used as a reason to withhold antibiotics from seriously ill patients with acute exacerbations of COPD, sepsis, or any other potential bacterial infection -- especially early in their clinical course."

Sodium Bicarbonate in Cardiac Arrest

emDocs - November 5, 2018 - Author: Murchison C - Edited by: Koyfman A and Long B
  1. The evidence for acidosis being harmful is primarily based on in vitro studies. Clinical data show acidosis may not be as harmful as we think. 
  2. Sodium bicarbonate therapy creates excess CO2 which must be quickly exhaled. If a patient is not adequately ventilating they will become more acidotic when given sodium bicarbonate therapy. 
  3. There are only two clinical trials on using sodium bicarbonate in cardiac arrest, both show no benefit. The AHA no longer recommends its use in ACLS."

Antipsychotics for delirium

PulmCrit - November 5, 2018 by Josh Farkas
..."Summary: The Bullet
  • MINDS-USA investigated the use of haloperidol or ziprasidone among a group of delirious ICU patients, 89% of whom had hypoactive delirium.
  • Haloperidol and ziprasidone were both ineffective. However, they were both also surprisingly safe (with comparable side-effect rates compared to placebo).
  • This study suggests that haloperidol and ziprasidone are ineffective for hypoactive delirium. This makes sense given the clinical features of hypoactive delirium (somnolence) and the variable neurobiological underpinnings of this disorder (making a single therapy unlikely to work for all patients).
  • All patients in the study were allowed to have open-label PRN antipsychotics for breakthrough agitation. Therefore, this study cannot reveal anything about this utilization of antipsychotics.
  • The receptor targets of atypical antipsychotics are widely variable. Thus, results obtained in this study are not necessarily generalizable to all antipsychotic medications."

Prehospital Plasma in Trauma

REBEL Cast Ep60 - November 5, 2018 - By Ashley Liebig
..."Different Outcomes in COMBAT and PAMPer:
  • Patients slightly older in PAMPer Trial vs COMBAT Trial (40’s vs 30’s)
  • More Crystalloid used in PAMPer Trial vs COMBAT Trial (500 – 900cc vs 150 – 250cc)
  • More Blunt Injury in PAMPer Trial vs COMBAT Trial (>80% vs ≈50%)
  • Transport Times Longer in PAMPer Trial vs COMBAT Trial 39 – 52min vs 16 – 28min
Clinical Take Home Point:
In injured patients at risk for hemorrhagic shock, pre-hospital administration of thawed plasma appears to be a safe and efficacious practice in reducing mortality. The difference in mortality outcomes between the COMBAT and PAMPer trials may simply be the longer transport times and the amount of crystalloids, which begs the question of whether we should be resuscitating these patients with crystalloid fluids at all?..."

domingo, 4 de noviembre de 2018

Hypothermia in brain injury

St. Emlyn´s - November 3, 2018 - By Dan Horner
..."We recently reported on the EuroTHERM trial3,4 that looked at rescue hypothermia in patients with severe traumatic brain injury refractory to standard tier 1 care. We felt the trial showed harm to patients in the hypothermia group, but did not answer the question as to whether hypothermia may be used as a prophylactic therapy in patients who are at the lower end of the severity spectrum, but remain at risk of secondary brain injury.
This month an international group reported the result of a randomised controlled trial in just such a group. The paper is published in JAMA and is (I think) currently open access. The abstract is below, but as we always say it’s vital that you read the full paper..."

Methanol Toxicity

EM@3AM - November 3, 2018 - Author: Bridwell R - Edited by: Long B and Koyfman A
  • Acidemia is greatest predictor of final visual acuity.9
  • Dose to cause permanent visual impairment is approximately 30cc, or a mouthful.
  • Delayed Parkinsonism and polyneuropathy can occur later.
  • John Milton, author of Paradise Lost, went blind from methanol poisoning."

FLORALI trial.

PulmCrit - November 1, 2018 - By Josh Farkas
"Summary The Bullet:
  • Conventional wisdom is that FLORALI is a positive trial, whereas HIGH is a negative trial. As such, these trials are portrayed as contradicting each other.
  • The actual data from FLORALI and HIGH are consistent. FLORALI isn’t quite as optimistic as it is commonly perceived, whereas HIGH isn’t quite as dreary as it has been described. The truth probably lies in between.
  • Evidence doesn’t show a mortality benefit from HFNC. However, combining data from HIGH and FLORALI does suggest a non-significant reduction in intubation rates. Such a reduction has been shown in two RCTs following extubation.4 5
  • HFNC is remarkably safe. None of these trials report any worrisome complications from HFNC.
  • Currently, benefit/risk analysis continues to favor the use of HFNC for hypoxemic respiratory failure. HFNC isn’t a magic bullet for hypoxemic respiratory failure, but it may help some patients and it is extremely safe."

jueves, 1 de noviembre de 2018

Heart Score

Porros EM - November 1, 2018 - By Dr. Po
..."¿Por qué es complejo de evaluar el dolor torácico? Según nuestra alida la Ñora Tintinalli el dolor torácico cuenta con 8 millones de consultas por año (USA), de estas consultas entre en 50 y 70% se estudian en urgencia pero aun así un 5% de los infartos al cuore los damos de alta desde la urgencia. La complejidad de esto es dada su amplia variedad de diferenciales y combinaciones de síntomas en la presentación, haciendo que nuestra toma de decisiones sea mas enredada que los planos del puente Cau-cau*.."

EVLI Airway Incrementalization

EMCrit 236 - October 31, 2018 - By Scott Weingart
"A video lecture from my friend and airway guru, Prof. George Kovacs. He has been obsessed with airway for decades. This lecture discusses breaking down the steps of airway management into chunks."


emDocs - October 31, 2018 - Authors: Toni Riveros and Michael Schindlbeck 
Edited by: Alex Koyfman and Brit Long
"Pearls & Pitfalls
  • Myocarditis remains a challenging diagnosis given its wide range in clinical presentation, from a subtle picture of mild dyspnea and malaise following a recent viral illness to fulminant congestive heart failure and sudden cardiac death.
  • Clinicians should investigate for clues including travel or immigration history, illicit drug use, underlying autoimmune conditions, transplant status, co-infections such as hepatitis or HIV, or treatment with chemotoxic or new antibiotic agents.
  • Physical exam findings may include tachycardia disproportionate to body temperature, a toxic appearance without a clear source of infection, or dyspnea with signs of circulatory overload in a patient with no known cardiac history.
  • Patients with myocarditis should be admitted to a setting capable of cardiac monitoring. Treatment in the ED is mainly supportive with careful attention to airway, breathing, and circulation."

martes, 30 de octubre de 2018

New Oncologic Emergencies

CanadiEM - By Arden Azim - October 30, 2018

Summary of Approach to Patients on Immune 
Checkpoint Inhibitors
In summary, immunotherapy drugs are increasingly used in the treatment of multiple malignancies.1–3 A broad spectrum of immunotherapy-related adverse events exists, with skin, GI tract and lungs most commonly affected.1–3 Immunotherapy is distinct from chemotherapy, and complications require a distinct approach to management. High-dose corticosteroids are the basis of emergency management for severe cases, along with supportive therapy and early consultation to medicine, oncology and other appropriate specialists.1–3 Careful medication reviews (look for drugs ending in “mab”) for oncology patients and a high index of suspicion for immunotherapy-related adverse events are key in the early detection of complications and appropriate management of these patients.
A tool-kit and guidelines by Cancer Care Ontario for management of immunotherapy toxicities can be found at: 

Manual de Urgencias

‘Manual de Urgencias’, tenemos nueva edición (la 3ª) del manual coordinado por Carlos Bibiano Guillén. Ha sido presentado el 22 de octubre en el Hospital Universitario Infanta Leonor, donde Bibiano es Jefe del Servicio de Urgencias."
Tamaño:14 Mb

Critical Care Reviews Book 2018

CCR Logo Promoting OA 080715 opt
"The Critical Care Reviews Book summarises, critiques and puts in context the biggest trials of the year. Five intensivists from Belfast, Northern Ireland, spend a year writing this in their own time. This is available as a free pdf download or at minimum cost for the print version. Critical Care Reviews is a not-for-profit organisation."


PulmCrit (EMCrit)
PulmCrit - October 30, 2018 - By Josh Farkas 
"Summary: The Bullet
  • Stress ulceration doesn’t significantly affect mortality. Therefore, there is no way that preventing stress ulceration could possibly improve mortality. The fact that SUP-ICU detected no mortality benefit was inevitable and doesn’t provide any new information about SUP. DVT prophylaxis doesn’t affect mortality either.
  • Pantoprazole did its job in this trial: it reduced the incidence of stress ulceration (by 50%) without any detectable toxicity (no increase in clostridium difficile or pneumonia rates). Lack of toxicity may favor use of pantoprazole as a front-line agent for SUP.
  • Pantoprazole reduced the incidence of clinically important GI bleeding by 1.7%, yielding a number needed to treat (NNT) of 59. This suggests that SUP should be restricted to a more highly selected population of patients, who are at greater risk of stress ulceration.
  • Further work is needed to define which patients may benefit from SUP. There is probably a role for it, but we’re using it too often."

sábado, 27 de octubre de 2018

Literature Review 2018

FOAMcast - Oct 16, 2018
"In this episode we highlight key articles in Emergency Medicine that came out, thus far, in 2018."



REBEL EM - Emergency Medicine Blog
R.E.B.E.L.EM - October 22, 2018 - By Salim Rezaie
"...Clinical Take Home Point: Because CTCA is an anatomic test, it appears to increase the certainty and frequency of coronary heart disease identification, which in turn changes treatment with preventative and anti-anginal medications, but also leads to more coronary angiography and revascularization in the short term (12months). With the newer AHA recommendations for lowered thresholds of preventative medication initiation, since the publication of the original SCOT-HEART study, it is not clear if CTCA would still result in improved long term outcomes. Additionally, with SCOT-HEART’s primary 5-year endpoint being driven by decreased non-fatal MI, an outcome that may be differently adjudicated based on the data ascertained from CTCA, even this improvement is suspect. Generally, with the publication of SCOT-HEART, the addition of CTCA to standard care can be definitively determined to have little benefit except to mitigate diagnostic uncertainty—a clinician-oriented benefit with minimal patient value. The only question that remains unanswered now is, does the initiation of preventative therapies (aspirin, statins, lifestyle modifications), coronary revascularization, or a combination of both strategies improve long-term patient oriented outcomes in patients with stable chest pain due to coronary heart disease?"

Performing Procedures

R.E.B.E.L.EM - October 24, 2018 - By Salin Rezaie
"Background: Establishing IV access has become the norm for patients presenting to the ED. However with increasing patient volumes, difficulty and delays in acquiring IV access, it seems that anything that could expedite care, reduce pain and suffering, and improve patient care would be welcomed in the ED. There are several tricks I have learned along the way to achieve just this: No IV access, no problem…performing procedures like a boss…"

sábado, 20 de octubre de 2018

Cricoid Pressure and RSI

St Emlyn’s - By Simon Carley - October 20, 2018
"...This month we have the publication of the larget trial to date on the use of cricoid pressure in emergency patients4. You can read the paper here and it appears to be open access at the moment...
What’s the clinical bottom line?
On the basis of this and other trials there is no compelling evidence for the use of cricoid pressure in operating department patients, but there is no real evidence of serious harm either. It looks likely that laryngoscopy may be easier without it in place.
So on balance, and arguably not on the strongest of evidence cricoid pressure is probably not doing a great deal in this group of patients.
What we don’t know is whether we can directly transfer that opinion to other groups, notably those in the ED. However, other studies, albeit smaller and less rigorous ones also question the effectiveness of cricoid in emergency patients8–11. In Virchester I’ll carry on not using it, but I accept that this is an evidence light decision."

ACEP 2018 Favorite pearls

R.E.B.E.L. EM - Emergency Medicine Blog
R.E:B.E.L.EM - October 18, 2018 - By Salim Rezaie
"This year ACEP 2018 took place in San Diego, CA from Oct 1st– 4th, 2018. There were lots of amazing speakers and topics as was evidenced by the eruption of everyone’s twitter feeds with the #ACEP18 hashtag. I was fortunate enough to not only attend, but also speak at this amazing conference. I was approached by several attendees requesting that I put together a list of my favorite pearls from this conference, as I have done in years past on REBEL EM. Below is my top 10 list, in no particular order..."


EM@3AM - October 20, 2018 - Author: Thrasher S, Sulava E
Edited by: Long B and Koyfman A
  • Occurs in insulin-dependent diabetes > non-insulin-dependent diabetes late > non-insulin-dependent diabetes early > Non Diabetic
  • POC Glucose should be part of initial altered mental status work-up
  • Causes: Lifestyle, drugs, alcohol, infection, autoimmune/neoplasm
  • D10 vs D50 for severely hypoglycemic patient? Remember D50 can cause rebound hypoglycemia
  • Glucagon can be used as a temporizing measure if no IV access
  • Sulfonylurea has specific treatment (+/- activated charcoal and octreotide)
  • Involve the specialists for further diagnostics and assistance"

Corticosteroides for COPD

PulmCCM - October 17, 2018
..."Most patients with severe COPD exacerbations should be treated with seven days or fewer of systemic corticosteroids. There is no reason to believe that longer steroid courses are helpful in patients with mild or moderate COPD either, although evidence is lacking for that conclusion. Some patients are exceptions and may require longer steroid courses to regain symptom control and functional status."

miércoles, 17 de octubre de 2018

Intranasal Analgesics

emDocs - October 17, 2018 - By Cisewski D
Edited by: Singh M, Alex Koyfman A  and Long B
"Last week on Pain Profiles we discussed a feasibility trial assessing the use of intranasal ketamine for pediatric musculoskeletal pain. A few weeks ago I had the pleasure of talking to Dr. Stacy Reynolds regarding her research with intranasal ketamine pediatric analgesia. [Recall: In 2017, Dr. Reynolds was the lead author on a landmark study presented at the SAEM Annual Conference assessing the feasibility of intranasal ketamine use among pediatric patients with extremity injuries. The results of this study provided supporting evidence for a large-scale, multi-center pediatric trial to assess the safety and efficacy of intranasal ketamine among pediatric population with extremity injuries.] The following is a re-print of an SAEM Pulse interview I did with Dr. Reynolds regarding her research, career interests, and advice for future research-driven students and residents interested in following in her footsteps."
emDocs - September 19, 2018 - By Cisewski D
Edited by: Singh M, Alex Koyfman A  and Long B
"So what’s the upshot?
IN ketamine resulted in an acceptable (tolerable) increase in side effects over IN fentanyl, and neither drug proved more efficacious in pain reduction. Having met each of these threshold criteria, the authors confirm that a larger pediatric trial to assess efficacy and safety of IN ketamine for acute extremity pain management is needed. IN administration is already a well-established technique, and this study is a further step toward a promising opioid-sparing analgesic alternative and delivery for pain management."