Journal club 25th January

Journal club 25th January -9am 

Click here for paper: 2016 Emerg Med J Manzano

Diagnostic performance of S100B protein serum
measurement in detecting intracranial injury in
children with mild head trauma

Sergio Manzano,1 Iris Bachmann Holzinger,2 Christian J Kellenberger,3
Laurence Lacroix,1 Dagmar Klima-Lange,4 Martin Hersberger,5 Giorgio La Scala,6
Stefan Altermatt,7 Georg Staubli2

Objective To assess the accuracy of S100B serum level
to detect intracranial injury in children with mild
traumatic brain injury.
Methods A multicenter prospective cohort study was
carried out in the paediatric emergency departments of
three tertiary hospitals in Switzerland between January
2009 and December 2011. Participants included
children aged <16 years with a mild traumatic brain
injury (GCS ≥13) for whom a head CT was requested by
the attending physician. Venous blood was obtained
within 6 h of the trauma in all children for S100B
measurement before a head CT was performed. As the
S100B value was not available during the acute care
period, the patient’s management was not altered. The
main measures were protein S100B value and the CT
Results 20/73 (27.4%) included children had an
intracranial injury detected on CT. S100B receiver
operating characteristics area under the curve was 0.73
(95% CI 0.60 to 0.86). With a 0.14 mg/L cut-off point,
S100B reached an excellent sensitivity of 95% (95% CI
77% to 100%) and 100% (95% CI 81% to 100%) in
all children and in children aged >2 years, respectively.
The specificity, however, was 34% (95% CI 27% to
36%) and 37% (95% CI 30% to 37%), respectively.
Conclusions S100B has an excellent sensitivity but
poor specificity. It is therefore an accurate tool to help
rule out an intracranial injury but cannot be used as the
sole marker owing to its specificity. Used with clinical
decision rules, S100B may help to reduce the number
of unnecessary CT scans

CLICK HERE FOR THE ARTICLE :Beaudoin_et_al-2014-Academic_Emergency_Medicine (1)

Acad Emerg Med. 2014 Nov;21(11):1193-202. doi: 10.1111/acem.12510.

Low-dose ketamine improves pain relief in patients receiving intravenous opioids for acute pain in theemergency department: results of a randomized, double-blind, clinical trial.

Beaudoin FL1, Lin C, Guan W, Merchant RC.
1The Department of Emergency Medicine, Rhode Island Hospital, The Alpert Medical School of Brown University, Providence, RI.



Low-dose ketamine has been used perioperatively for pain control and may be a useful adjunct to intravenous (IV) opioids in the control of acute pain in the emergency department (ED). The aim of this study was to determine the effectiveness of low-dose ketamine as an adjunct to morphine versus standard care with morphine alone for the treatment of acute moderate to severe pain among ED patients.


A double-blind, randomized, placebo-controlled trial with three study groups was conducted at a large, urban academic ED over a 10-month period. Eligible patients were 18 to 65 years old with acute moderate to severe pain (score of at least 5 out of 10 on the numerical pain rating scale [NRS] and pain duration < 7 days) who were deemed by their treating physician to require IV opioids. The three study groups were: 1) morphine and normal saline placebo (standard care group), 2) morphine and 0.15 mg/kg ketamine (group 1), or 3) morphine and 0.3 mg/kg ketamine (group 2). Participants were assessed at 30, 60, and 120 minutes after study medication administration and received rescue analgesia as needed to target a 50% reduction in pain. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the NRS and calculated as the summed pain-intensity (SPID) difference over 2 hours. The amount and timing of rescue opioid analgesia was evaluated as a secondary outcome. The occurrence of adverse events was also measured.


Sixty patients were enrolled (n = 20 in each group). There were no differences between study groups with respect to age, sex, race/ethnicity, preenrollment analgesia, or baseline NRS. Over the 2-hour poststudy medication administration period, the SPIDs were higher (greater pain relief) for the ketamine study groups than the control group (standard care 4.0, interquartile range [IQR] = 1.8 to 6.5; group 1 7.0, IQR = 4.3 to 10.8; and group 2 7.8, IQR = 4.8 to 12.8; p < 0.02). The SPIDs for the ketamine groups were similar (p < 0.46). When compared to standard care, group 2 sustained the reduction in pain intensity up to 2 hours, whereas group 1 was similar to standard care by 2 hours. Similar numbers of patients received rescue analgesia: standard care group, seven of 20, 35%; group 1, four of 20, 20%; and group 2, four of 20, 20% (p = 0.48). Among those receiving rescue analgesia, those in the standard care group received analgesia sooner than either low-dose ketamine group, on average. More participants in the low-dose ketamine groups reported dysphoria and dizziness.


Low-dose ketamine is a viable analgesic adjunct to morphine for the treatment of moderate to severe acute pain. Dosing of 0.3 mg/kg is possibly more effective than 0.15 mg/kg, but may be associated with minor adverse events. Future studies should evaluate additional outcomes, optimum dosing, and use in specific populations.

© 2014 by the Society for Academic Emergency Medicine.

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