Pain In Emergency Department Research Articles

Chest Pain in the Pediatric Emergency Department: Evaluation of Clinical and Laboratory Findings of Patients

Chest Pain in the Pediatric Emergency Department: Evaluation of Clinical and Laboratory Findings of Patients

Geriatric mortality risk factors in emergency department for non-traumatic abdominal pain.

The study aimed to determine the factors affecting the mortality of geriatric patients presenting to the emergency department with non-traumatic abdominal pain, as well as the associations of these factors with mortality. With the increasing number of elderly patients, early recognition of patients with risk-bearing diagnoses is crucial. This prospective cross-sectional study included 466 patients over 65 years of age who were admitted to THE emergency department of a tertiary hospital and consented to participate. Data was collected on patient demographics, vital signs, chronic diseases, laboratory investigations, diagnoses, disposition, and 30-day mortality. The results showed that the mean patient age was 74.42 years, with 47.4 % being male and 52.6 % female. 15.6 % of the patients had nonspecific causes. The risk of mortality within one month was 5.797 times higher in patients with neurological diseases and 5.183 times higher in those with a history of surgery. A one-unit decrease in hemoglobin increased the mortality risk by 0.656 times. This study highlights the importance of careful evaluation of elderly patients with neurological diseases, previous surgical history, and anemia in the emergency department with non-traumatic abdominal pain (Tab. 5, Ref. 18).

Gastric Pneumatosis and Its Gastrofibroscopic Findings in Life-Threatening Superior Mesenteric Artery Syndrome Complicated by Anorexia Nervosa in a Child.

A 14-year-old girl was admitted to the emergency department for excessive bile-containing vomiting and severe abdominal pain. She had been healthy until she intentionally lost 25 kg over a 6-month period. Thick, bloody bile-mixed food particles were drained from the stomach through a nasogastric tube. Abdominal computed tomography revealed huge stomach dilatation with extensive gastric pneumatosis, possible near rupture, acute pancreatitis, and a very narrow third of the duodenum, indicating superior mesenteric syndrome. Gastrofibroscopy revealed multiple hemorrhagic ulcers and numerous bead-like cystic lesions in the stomach. Laboratory examination results were notable for severe deficiencies in critical nutrients, including iron, zinc, proteins, and prealbumin, as well as undernutrition-associated endocrine complications such as hypothyroidism and hypogonadotropic hypogonadism. Excessive vomiting ceased after the endoscopic removal of stagnant gastric contents. Gastric pneumatosis improved after 3 days of supportive care.

Submucosal infiltrate of anisakis larvae. Rare cause of intestinal obstruction.

Patient aged 71 with a history of type 2 diabetes mellitus. He came to the emergency department for abdominal pain and vomiting. Laboratory tests showed an increase in acute phase reactants. Abdominal CT scan showed dilated jejunal loops, compatible with intestinal occlusion. Urgent intervention was performed, resecting the affected segment. The pathology report showed a prominent transmural inflammatory infiltrate and interstitial oedema, with moderate villous atrophy, identifying parasitic structures compatible with anisakis larvae (family Anisakidae). Given the mechanism of tissue invasion, the larvae are surrounded by a predominantly eosinophilic inflammatory infiltrate, organised as granulomas or abscesses.

What is happening in that urinary catheter bag?

An 86-year-old nursing home woman with an indwelling urinary catheter presented to our emergency department for abdominal pain, nausea, hyporexia after nine days of stubborn constipation despite the use of laxatives, on a background of IV stage Chronic Kidney Disease (CKD), type 2 diabetes, hypothyroidism, and bed rest syndrome with chronic pain treated with fentanyl transdermal patch. Blood tests showed a worsening of renal function (creatinine 5.7 mg/dL, nv 0.6-1; azotemia 177 mg/dL, nv 10-50), and increased C reactive protein value (5 mg/dL, nv < 0.5). Glucose and serum electrolytes were normal. Abdomen X-ray was unremarkable, and PoCUS excluded hydronephrosis and bladder globe. The urine drainage bag was purple with smelly urine.

A rare and unusual cause of acute abdominal pain: A case of spontaneous isolated dissection of the celiac trunk

Spontaneous dissection of the celiac trunk is a rare and uncommon cause of acute abdominal pain. Risk factors, natural history and optimal treatment are still unclear due to the rarity of the disorder. Therapeutic strategies and follow-up procedures are based on limited observations, and the absence of guidelines warrants a patient-tailored approach. We report the case of a 50-year-old woman who presented to our emergency department for epigastric pain, nausea, and vomiting resulting from a spontaneous dissection of the celiac trunk, successfully treated endovascular technique.

652 SUCCESSFUL SURGICAL REPAIR OF LEFT VENTRICULAR PSEUDOANEURYSM IN A PATIENT WITH SUBACUTE ST-ELEVATION MYOCARDIAL INFARCTION

Abstract A 65-year-old man was admitted to the emergency department for abdominal pain begun 4 days before. Past medical history consisted of ischemic stroke and diabetes mellitus. Of note, he was not taking any medication. Vital signs: blood pressure 90/50 mmHg, heart rate 50/minute, respiratory rate 18/minute, body temperature 36.5°C; saturation oxygen level 93%. High-sensitivity cardiac troponin was mildly elevated (121 pg/mL). Electrocardiogram showed sinus bradycardia, Q waves with ST elevation in antero-lateral leads consistent with subacute STEMI. Transthoracic echocardiogram (TTE) revealed aneurysmatic expansion of apical left ventricular (LV) walls (ejection fraction 30%) with a large apical thrombus (35×15 mm). Coronary angiography showed complete occlusion of proximal left anterior descending artery and a critical stenosis of right coronary artery; percutaneous coronary intervention with stent implantation on right coronary artery was performed. He received triple antithrombotic therapy with aspirin, clopidogrel, intravenous heparin first and then oral anticoagulation with warfarin. During coronary care unit stay, the patient was asymptomatic and hemodynamically stable. However, a control TTE (day 6) in cardiology ward revealed the presence of pseudoaneurysm with an oval out-pouching (23 × 13 mm) from the apical aspect of LV septum, communicating with the LV chamber through a passage measuring 1.6 cm. Partially organized pericardial effusion was evident around right ventricular free wall (Figure 1). Thus, the patient was immediately transferred to the cardiac surgery department for urgent surgical repair. The LV anterior wall rupture with pseudoaneurysm was then treated with endoaneurysmectomy of the LV with dacron patch and freewall reconstruction with prolene sutures and teflon felt stripes. The patient was finally discharged 3 weeks after surgery with betablockers, ace- inhibitors, diuretics, statins and dual antiplatelet therapy with aspirin and clopidogrel. At one month follow-up visit, the patient was hemodynamically stable with acceptable functional capacity. Figure 1Modified five chamber view (a, b) and three chamber view (c, d) showing apical LV pseudoaneurysm (arrows) with moderate pericardial effusion (arrowhead); color Doppler through the passage (arrow) in 3 chamber view (d). LV, left ventricular.

Role of Triple Rule-Out Computed Tomography Angiography in the Management of Covid-19 Patients Presenting with Acute Chest Pain in Emergency Department

Role of Triple Rule-Out Computed Tomography Angiography in the Management of Covid-19 Patients Presenting with Acute Chest Pain in Emergency Department

PATIENTS PRESENTING WITH CHEST PAIN TO CARDIAC EMERGENCIES SERVICES AND APPLICATION OF TIMI RISK SCORE FOR BETTER OUTCOME

Objectives: To determine the frequency of Patients presenting with chest pain in emergency department and application of TIMI Risk score for patients outcome.
 Methodology: This study is prospective observational cohort study and an analysis was conducted in 1654 adult patients presenting with chest pain syndrome from Mar 2021 to Oct 2022 at Khyber teaching hospital and an electrocardiogram was performed to evaluate these patients. TIMI risk scores determined at ED presentation. The main outcome was the composite of death, acute myocardial infarction (MI), and revascularization within 30 days.
 Results: The TIMI risk score at ED presentation successfully risk-stratified this unselected cohort of chest pain patients with respect to 30-day adverse outcome, with a range from 2.6%, with a score of 0, to 100%, with a score of 7. The highest correlation of an individual TIMI risk indicator to adverse outcome was for elevated cardiac biomarker, (Trop hs I) at admission. Overall, the score had similar performance characteristics to that seen when applied to other databases of patients enrolled in clinical trials and registries using a 14-day end point.
 Conclusion: The TIMI risk score can be a used as tool for risk stratification of patients with chest pain at emergency department.

Post Prostatectomy Abdominal Pain

A 56-year-old man with a history of prostate cancer presented to the emergency department (ED) for abdominal pain, vomiting, and tenesmus. Four days before the presentation, he had undergone robotic radical prostatectomy. His examination was significant for diffuse abdominal tenderness without frank peritonitis. Although his vitals were initially normal, he became progressively more hypotensive despite fluid resuscitation and eventually required vasopressors. Laboratory evaluation revealed an anion gap metabolic lactic acidosis with a normal WBC count. Initial computed tomography of the abdomen and pelvis with intravenous contrast (Figure 1) showed mild nonspecific circumferential thickening of the distal rectum. Because of the patient’s clinical deterioration, he was sent for repeat computed tomography with rectal contrast (Figure 2), which revealed his diagnosis.Figure 2Computed tomography of the abdomen and pelvis with rectal contrast (axial view) showing rectal perforation, with the rectal contrast extending through a full-thickness defect at the 10 o’clock position of the lower rectum into the pelvis and peritoneal cavity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Postoperative rectal perforation. The patient was treated with antibiotics and was immediately taken to the operating room for abdominal washout, which revealed 3 L of feculent material in the abdomen. He had a prolonged hospital stay and was discharged to a skilled nursing facility 1 month later. Postoperative rectal injury is a rare but known complication of robotic radical prostatectomy. Most cases are discovered and repaired during surgery. However, cases that are not diagnosed during surgery often have significant morbidity.1Wedmid A. Mendoza P. Sharma S. et al.Rectal injury during robot-assisted radical prostatectomy: incidence and management.J Urol. 2011; 186: 1928-1933Crossref PubMed Scopus (42) Google Scholar Therefore, a high index of suspicion is needed to diagnose postoperative rectal injuries, and it is one of the few instances when rectal contrast should be routinely considered.2Marres C.C.M. Engelmann E.W.M. Buskens C.J. et al.The importance of rectal contrast in CT assessment to detect anastomotic leakage after colorectal surgery.Colorectal Dis. 2021; 23: 2466-2471Crossref PubMed Scopus (2) Google Scholar Those cases identified in the ED will require admission and surgical consultation because their management requires bowel diversion with delayed fistula closure.

Impact of Arginine Therapy on Clinical Outcomes, Mitochondrial Function and Oxidative Stress in Children with Sickle Cell Disease Hospitalized with Vasoocclusive Pain Episodes: A Randomized Controlled Trial

Introduction: Vaso-occlusive pain episodes (VOE) are the leading cause of emergency department (ED) visits & hospitalization in patients with sickle cell disease (SCD). During SCD-VOE, patients develop an acute arginine (Arg) deficiency. Supplementation with Arg has shown opioid-sparing effects, improves blood pressure & cardiopulmonary function & decreases length of hospital stay. Though we have previously demonstrated that intravenous (IV) Arg improves mitochondrial (mito) function, the precise mechanisms by which Arg mediates these positive effects remain unclear. Objectives: To determine the role of IV Arg as adjuvant in the management of SCD-VOE Methods: Prospective single-center double-blind randomized controlled trial (RCT) of IV Arg (TID, up to 7 days) in children with SCD age 3-21 years hospitalized for VOE requiring IV opioids. Patients with significant liver/renal dysfunction or those previously enrolled were excluded. Subjects were randomized into 1 of 3 arms: 1) 100 mg/kg/dose Arg, standard dose (SD), 2) loading dose: 200 mg/kg followed by SD or 3) placebo. Demographics, total parenteral opioid (TPO) use (morphine equivalents, mg/kg) time to crisis resolution (time of study drug delivery to last IV opioid in hours), pain scores, patient reported outcomes (PROMIS) & mito function were obtained before treatment & at discharge. The primary outcome measure was TPO use between study arms. Hypothesis tests & unadjusted & covariate-adjusted fixed & mixed effects generalized linear regression models were used, as appropriate, to compare cross-sectional & longitudinal outcomes within & between randomization arms. This protocol utilized IND#66943 (Sponsor-Morris), registered with ClinicalTrials.gov (NCT02536170). Results: 1,548 patients were screened, 266 were eligible, 114 consented, & 108 were randomized. Safety results of this RCT have been previously reported (Reyes et al, Am J Hematol 2022). Demographics & clinical outcomes of subjects randomized by treatment arm are provided in Table 1. While statistically insignificant, there was a clinically relevant decrease in TPO & time to crisis resolution in both Arg arms compared to placebo. The placebo group required 45% higher TPO & experienced >15 hours longer mean time to crisis resolution compared to combined Arg-treated groups when adjusted for HU use, continuous age and sex. Among children <17 years, the placebo group (n=33) required 80% more TPO compared to combined Arg groups (n=57; p=0.075). No differences in ED vs discharge pain scores or patient/parent PROMIS reports across arms were found. Mito Complex V activity was higher (p=0.02) & protein carbonyl levels were lower (p=0.003) at ED visit in patients on Hydroxyurea (HU). Notably mito Complex IV & V activity increased significantly in both Arg arms while there was no change in the placebo group (Fig 1, p<0.001); protein carbonyl levels in platelet rich plasma decreased in both Arg groups (Fig 1, p<0.001), suggesting a decrease in oxidative stress that increased in the placebo arm (p=0.02). Greatest mito improvement occurred with Arg loading dose. Conclusion: Arg supplementation increases mito activity & decreases oxidative stress in children with SCD-VOE. This is the first report to suggest a HU-related impact on mito activity in SCD. Prior reports show that Complex V inhibition leads to increased mito oxidant production in platelets from SCD patients. Acute improvements in Complex IV & V function & decreased oxidative markers with Arg therapy are consistent with Arg-induced reductions in mito oxidant generation. Arg therapy improves symptoms associated with MELAS syndrome (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes) suggesting an impact of Arg on mito activity that may be beneficial in SCD. Given emerging data supporting a link between mito function and pain, improved mito activity may mechanistically contribute to decreased pain & ultimately less opioid requirement with IV Arg treatment, as well as have further implications for improved metabolism and oxidative signaling in SCD. In this RCT, Arg therapy also demonstrated clinically relevant opioid-sparing & a decreased time to crisis resolution that was statistically insignificant. A larger sample size may elucidate potential differences; we are currently enrolling 360 children in an ongoing PECARN-endorsed multicenter Phase 3 RCT (SCD Treatment with Arg Therapy - STArT). Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Effectiveness of Procedural Sedation and Analgesia in Pediatric Emergencies. A Cross-Sectional Study

IntroductionPain is defined as an unpleasant emotional and sensory experience associated with bodily harm or with situations that cause fear and anxiety. However, it is often undertreated in pediatric emergency departments. This study aims to assess the effectiveness of sedation-analgesia techniques, level of satisfaction among health care professionals and relatives, and agreement between the satisfaction of health care professionals and relatives. MethodsA cross-sectional design was conducted. Sociodemographic and clinical variables were recorded, together with those for effectiveness using the Face, Legs, Activity, Cry, and Consolability scale and the Wong-Baker FACES scale, and the satisfaction using the 10-point Likert scale. Stata 16.1 was used for data analysis. ResultsA total of 94 procedures were registered. The results suggested that these techniques were effective or mildly effective in only half of the cases. Satisfaction was considered good across the board, and the agreement between health care professionals (ie, pediatric nurses and pediatricians) was considered substantial. However, the agreement between health care professionals and relatives was moderate. DiscussionOur results suggested that the adequate management of pain in pediatric emergency departments is still a challenge, despite the availability of international guidelines. Future research lines should be focused on analyzing possible causes of the inefficacy of some sedation-analgesia techniques and the causes of the differences between the perspectives of health care professionals and relatives. These research lines may be useful to improve quality of care and pediatric patient comfort.

Ultrasound-Guided Erector Spinae Plane Block in Emergency Department for Abdominal Malignancy Pain: A Case Report.

Severe breakthrough pain is a common occurrence in patients with cancer and is responsible for thousands of emergency department (ED) visits each year. While opioids are the current mainstay of treatment, they have multiple limitations including inadequate control for a quarter of patients with cancer. The ultrasound-guided erector spinae plane block (ESPB) has been used in the ED to effectively treat pain for pathologies such as acute pancreatitis, since it provides somatic and visceral analgesia. In this case report we describe the use of an ESPB to treat breakthrough pain safely and effectively in a 54-year-old female with a history of metastatic colon cancer. The ESPB may have utility in addressing well documented disparities in pain treatment in the ED, but additional research is needed to understand side effects, duration of pain control, and clinical outcomes of the ESPB.

Ruptured ectopic pregnancy as complete hydatidiform mole: Case report and review of the literature

Usually, a hydatidiform mole (HM) develops inside the uterus. The occurrence of HM in ruptured tubal pregnancy is exceptional. Cases reported in the literature are scarce. In this article, a case of haemoperitoneum secondary to a ruptured fallopian tube by a complete mole is reported. A 50-year-old gravida 2, para 1 was admitted to the emergency department for acute abdominal pain. After the clinical examination, an abdominal sonography and CT scan were done, revealing the presence of an adnexal left mass associated with an important haemoperitoneum. A urine pregnancy test was done and was positive, indicating an immediate laparoscopic exploration. The laparoscopy revealed a haemoperitoneum secondary to a ruptured tubal mass. The pathological exam concluded a complete hydatidiform mole (CHM) invading the wall of the fallopian tube. Any acute abdominal pain in a potentially pregnant woman imposes first the routine realization of a pregnancy test. The occurrence of CHM in a ruptured fallopian tube is particularly rare and has exceptionally been diagnosed before the laparoscopic exploration.

Annals for Educators - November 2022

Annals for Educators - November 2022

ODP450 A Case of Metastatic Medullary Thyroid Cancer Presenting with Pathologic Hip Fracture

Abstract Introduction Medullary thyroid cancer accounts for less than 5% of thyroid malignancies. Distant metastatic disease typically presents in lymph nodes, lung, liver and bone. We present a patient who initially presented with a pathologic hip fracture with bone biopsy revealing medullary thyroid carcinoma. Case Description A 44-year-old male with no past medical history presented to the emergency department for right hip pain following a mechanical fall. Imaging showed a right femoral neck pathologic fracture as well as lytic lesions within the right femoral neck and right ilium. Family history was significant for pancreatic cancer and breast cancer. The patient underwent bone biopsy of the right femur followed by total hip arthroplasty. Bone biopsy revealed metastatic medullary thyroid carcinoma. Thyroid ultrasound showed a 1.2 centimeter right solid hypoechoic nodule along with extensive cervical lymphadenopathy. Further imaging revealed metastatic disease throughout the thoracic spine, mediastinal lymphadenopathy, and a left 2.2 centimeter adrenal lesion with peripheral enhancement and possible necrosis. Carcinoembryonic antigen (CEA) level was 551 ng/mL (normal &amp;lt;4.7), calcitonin was 2,498 pg/mL (normal &amp;lt;10), and calcium levels were normal. Plasma free metanephrines were normal and plasma normetanephrines were less than two times the upper limit of normal. Genetic testing on the bone biopsy specimen revealed a RET p. C618S variant. Germline RET testing was collected. The patient was discharged with close follow-up with oncology to initiate systemic therapy and follow-up with endocrinology for the adrenal mass. Discussion Majority of cases of medullary thyroid carcinoma are sporadic. Patients typically present with a thyroid nodule with many having cervical lymph node involvement at diagnosis and 5-10% having distant metastatic disease. Our patient's initial presentation was unique in that he presented with a pathologic fracture. Bone metastases can be seen in about 30% of cases of metastatic medullary thyroid carcinoma. Calcitonin levels greater than 500 pg/mL require additional imaging to exclude metastatic disease. If RET mutational status is unknown, patients should be screened for primary hyperparathyroidism and pheochromocytoma. Screening for pheochromocytoma is critical in preoperative management of these patients. Treatment for patients with metastatic disease involves surgery, external beam radiotherapy, and kinase inhibitors. Presentation: No date and time listed

Differential diagnosis in children with musculoskeletal pain in Emergency Department

Objective: The study was aimed to analyze the diagnostic approach to a child with a non-traumatic musculoskeletal pain registered in the pediatric Hospital Emergency Department (HED). Since the pandemic COVID-19 affects patient health and the healthcare system, we also evaluated the impact of pandemic on type of musculoskeletal symptoms.&#x0D; Study design: A retrospective cross-sectional study was conducted by statistical analysis of data of patients with non-traumatic musculoskeletal pain registered in HED between January 2018 and December 2020. Data of patients referred and not referred to hospital ward and admitted to HED before and during COVID-19 pandemic have been compared.&#x0D; Results: Majority of patients presented acute, non-trauma related, single-site pain, usually localized in the hip, the knee and the spine. 21,49% of patients were referred to a hospital ward, usually rheumatological, neurological or orthopedic. Final diagnoses in almost ¾ patients belong to the group of musculoskeletal system and connective tissue disorders. During the pandemic significantly less patients with musculoskeletal pain reported to our HED. The duration of symptoms before admission was not significantly longer than in previous years, but the problem in children and the impact of the pandemic on the musculoskeletal system in children is complex.&#x0D; Conclusions: Our study provides detailed information on patterns of pediatric musculoskeletal consultations in HED. A positive history of trauma preceding musculoskeletal pain in a child may only be accidentally related to the final cause. Musculoskeletal pain can be also a symptom of a lot of various systemic conditions, not only diseases of the musculoskeletal system. The still ongoing COVID-19 pandemic may require changes in the organization of the HED. We believe that the presented results can help in organizing and planning care in pediatric HEDs, develop diagnostic algorithms and training for HED staff.

S3039 Hepatic Undifferentiated Pleomorphic Sarcoma Mimicking Liver Abscess

Introduction: Undifferentiated pleomorphic sarcoma (UPS) has been recognized as one of the most common malignant soft tissue tumors. It usually affects the elderly population and involves the extremities. However, hepatic UPS is rare. Fewer than 200 cases have been reported. Primary hepatic UPS occurs in late adulthood. It typically presents with a solid hepatic mass with regional lymph node involvement. Occasionally, UPS mimics hepatic infection clinically. Here we report a case of hepatic UPS, mimicking the presentations of liver abscess. Case Description/Methods: A 44-year-old female with a past medical history of hypertension presented at the emergency department (ED) for right upper abdominal pain for one week. The pain was described as dull, 5/10 on a pain scale, non-radiating, and associated with nausea, fever, and chills. The pain was worsened by sitting up and alleviated by lying down. At ED, the patient’s vital signs were within normal range. Physical examination showed right upper quadrant tenderness, without rebound, guarding, or rigidity. She was found to have slightly elevated liver enzymes and alkaline phosphate. CT of the abdomen revealed an irregular hypodense mass at the right hepatic lobe measuring 14.3 x 11.6 cm and a 2.6cm enlarged porta hepatis lymph node. The patient was admitted for further evaluation. Concerning possible liver abscess, the blood culture was collected, and the patient was treated with empiric antibiotics. Tumor markers including AFP, and CEA were within normal range. The blood culture was negative for infection. To rule out malignancy, PET scan was performed and showed a hypermetabolic mass with necrotic components in the liver. The patient underwent a liver biopsy. The pathology revealed extensively necrotic pleomorphic round cells with eosinophilic cytoplasm and variably sized, oval nuclei, indicating hepatic undifferentiated pleomorphic sarcoma. Oncology was consulted and recommended doxorubicin and ifosfamide for neoadjuvant chemotherapy. The patient was discharged to home to follow up with oncology as outpatient for chemotherapy and surgery for tumor resection. (Figure) Discussion: Hepatic UPS is a rare malignant mesenchymal tumor. Nonspecific clinical symptoms, unmarkable laboratory findings, and rapid tumor growth lead to poor prognosis. Physicians should be aware of this rare disease as a differential diagnosis for liver mass. Surgical resection is the preferred treatment. Chemotherapy could be used as neoadjuvant or adjuvant treatment to improve the survival rate.Figure 1.: a large liver mass noticed on CT of abdomen with contrast.

397 Assessment of Sociodemographic Disparities in Emergency Department Pain Management

397 Assessment of Sociodemographic Disparities in Emergency Department Pain Management

247 Comparison of Nebulized Sub-Dissociative Dose Ketamine at Three Different Dosing Regimens for Treating Acute Pain in the Pediatric Emergency Department: A Prospective, Randomized Double-Blind Trial

Currently, there are no clinical trials evaluating the role of nebulized ketamine in managing pain in the Pediatric ED. Our aim was to assess and compare the analgesic efficacy and rates of adverse effects of ketamine administered via breath-actuated nebulizer at three different dosing regimens (0.75mg/kg, 1 mg/kg and 1.5 mg/kg) for emergency department pediatric patients presenting with acute and chronic painful conditions.