Ketamine: Pediatric Procedural Sedation In The Emergency Department

Madati, Jamil P. MD
Krauss, Baruch MD
Luhmann, Jan MD
Sacchetti, Alfred MD

¹Assistant Professor, University of California San Diego School Of Medicine, San Diego, CA
²Attending, Division of Emergency Medicine, Children's Hospital Boston; Associate Professor of Pediatrics, Harvard Medical School, Boston, MA
³Instructor, Pediatrics, Division of Pediatric Emergency Medicine St. Louis Children's Hospital, St. Louis, MO
⁴Associate Director Emergency Services, Our Lady of Lourdes Medical Center, Camden, NJ

Pediatric Emergency Medicine Practice 8(1):p 1-15, January 2011.

You are in the middle of a busy evening shift, and there are 2 children in the ED awaiting procedural sedation. One patient is waiting for fracture reduction by the orthopedic surgeon. The other has a complex laceration of the vermilion border of the lip. The waiting room is starting to fill up with more patients checking in at triage, and you see there are several more patients in the waiting room that may require sedation for fracture reductions, lumbar punctures, and abscess incision and drainage. You realize that time is of the essence, and you approach the 2 patients and start to plan for the safest, most-efficient, effective sedation.

Patient 1 is a 6-year-old boy with a right forearm injury sustained when he fell off a trampoline and landed on his outstretched hand. No head injury is reported. The examination is notable for an angulated deformity of his right forearm which is confirmed on x-rays as a midshaft radius and ulnar fracture, but no findings are suggestive of intracranial or intraocular injuries. This child is in significant pain, and his parents are urging that some medication be given. He last ate 4 hours ago and last had liquid 2 hours ago. He has a history of mild intermittent asthma but with no recent exacerbations or hospitalizations. The patient has no prior surgeries, sedations, or known drug allergies.

What sedative agent would be the most efficient and effective (from start to recovery) for this patient?
What are the contraindications?
Would giving narcotics for analgesia lead to complications during his later sedation?

Patient 2 is a 2-year-old girl with a complex (jagged and deep) laceration through the vermillion border of her lower lip, sustained when she tripped and fell, cutting her lip on the edge of a coffee table. There was no loss of consciousness and no dental trauma. She last ate and drank 2 hours ago. Past medical and surgical history is noncontributory. The family is requesting that a plastic surgeon perform the repair, and Plastic Surgery requests that procedural sedation be used during laceration repairs.

Is it safe to perform procedural sedation on a patient who has been 2 hours NPO for both solids and liquids?
Should atropine be used in conjunction with ketamine to limit excessive salivary secretions during the procedure?
Should this patient be considered as having a head injury and would this be a contraindication to ketamine use in this patient?