JBJS | Ketamine Sedation for the Reduction of Children's Fractures in the Emergency Department*

The Journal of Bone & Joint Surgery, Volume 82, Issue 7

Articles | July 01, 2000

Ketamine Sedation for the Reduction of Children's Fractures in the Emergency Department*

Eric C. McCarty, M.D.†; Gregory A. Mencio, M.D.‡; L. Anderson Walker, M.D.§; Neil E. Green, M.D.‡

Investigation performed at the Department of Orthopaedics and Rehabilitation and the Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Vanderbilt University Sports Medicine Center, 2601 Jess Neely Drive, Nashville, Tennessee 37212.
‡Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, MCN D-4207, Nashville, Tennessee 37232-2550.
§Department of Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, Nashville, Tennessee 37232-4700.

The Journal of Bone & Joint Surgery. 2000; 82:912-912

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Abstract

Background: There recently has been a resurgence in the utilization of ketamine, a unique anesthetic, for emergency-department procedures requiring sedation. The purpose of the present study was to examine the safety and efficacy of ketamine for sedation in the treatment of children's fractures in the emergency department.

Methods: One hundred and fourteen children (average age, 5.3 years; range, twelve months to ten years and ten months) who underwent closed reduction of an isolated fracture or dislocation in the emergency department at a level-I trauma center were prospectively evaluated. Ketamine hydrochloride was administered intravenously (at a dose of two milligrams per kilogram of body weight) in ninety-nine of the patients and intramuscularly (at a dose of four milligrams per kilogram of body weight) in the other fifteen. A board-certified emergency physician skilled in airway management supervised administration of the anesthetic, and the patients were monitored by a registered nurse. Any pain during the reduction was rated by the orthopaedic surgeon treating the patient according to the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS).

Results: The average time from intravenous administration of ketamine to manipulation of the fracture or dislocation was one minute and thirty-six seconds (range, twenty seconds to five minutes), and the average time from intramuscular administration to manipulation was four minutes and forty-two seconds (range, sixty seconds to fifteen minutes). The average score according to the Children's Hospital of Eastern Ontario Pain Scale was 6.4 points (range, 5 to 10 points), reflecting minimal or no pain during fracture reduction. Adequate fracture reduction was obtained in 111 of the children. Ninety-nine percent (sixty-eight) of the sixty-nine parents present during the reduction were pleased with the sedation and would allow it to be used again in a similar situation. Patency of the airway and independent respiration were maintained in all of the patients. Blood pressure and heart rate remained stable. Minor side effects included nausea (thirteen patients), emesis (eight of the thirteen patients with nausea), clumsiness (evident as ataxic movements in ten patients), and dysphoric reaction (one patient). No long-term sequelae were noted, and no patients had hallucinations or nightmares.

Conclusions: Ketamine reliably, safely, and quickly provided adequate sedation to effectively facilitate the reduction of children's fractures in the emergency department at our institution. Ketamine should only be used in an environment such as the emergency department, where proper one-on-one monitoring is used and board-certified physicians skilled in airway management are directly involved in the care of the patient.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Fractures in children are common. In our experience, most (approximately 65 percent) of these fractures have been closed and have involved the upper extremity. When possible, a closed reduction of the fracture is preferable, and, in this age of cost containment, it is better to reduce the fracture in an outpatient setting, such as the emergency department, than in the operating room. The cost of managing closed fractures in the emergency department has been noted to be 70 to 80 percent less (approximately $3600 less)¹⁰ than treatment in the operating room^3,10. Other factors, such as time and logistics, may also favor reduction in the emergency department. However, in order for a physician to be able to perform satisfactory closed treatment of musculoskeletal injuries in an emergency-department setting, safe and effective levels of sedation and analgesia are essential to minimize pain and allay the apprehensions of the child. Factors to consider in choosing a technique include the ease of administration, efficacy, safety, amnestic effects, analgesic effects, sedative effects, duration of effects, reliability, patient and parent acceptance, and cost³⁵.

Numerous methods of sedation or analgesia, or both, for fracture reduction have been described in the orthopaedic literature^{1,3,4,6,10,13,17-19,21,26,36}. These methods include a variety of local and regional blocks (a hematoma block, intravenous regional anesthesia, an axillary block, and a femoral nerve block), several methods of conscious sedation (self-administered nitrous oxide, parenteral narcotics, and benzodiazepines), and combinations of sedation and a block (nitrous oxide and a hematoma block). Local and regional techniques are particularly effective for upper-extremity fractures. Sedation is more applicable in a broader sense in that it is not as specific as regional anesthesia and is suitable for patients over a wider age-range.

A variety of medications is used for sedation of pediatric patients. A particularly effective type for pediatric procedures in the emergency department is ketamine hydrochloride. Ketamine hydrochloride is a phencyclidine-derived agent that produces a dissociative anesthesia. A cataleptic state is induced, as functional and electrophysiological dissociation occurs between the cortical and limbic systems of the brain¹⁶. The anesthetic was first introduced thirty years ago and has been used extensively in third-world countries, but it has only recently become popular in emergency departments in the United States for procedures that require analgesia or sedation, or both^24,32. The safety and efficacy of ketamine have been well documented in more than 11,000 pediatric procedures, including a small number of orthopaedic procedures¹⁶. It is quick and reliable in producing a unique combination of sedation, amnesia, and analgesia. Ketamine has even been reported as the ideal anesthetic for use in children in the emergency department³⁴.

To our knowledge, there have not been any prospective studies devoted solely to the evaluation of the effectiveness of ketamine sedation during the treatment of fractures in children in the emergency department. The purpose of our prospective study was to investigate the efficacy and safety of ketamine during such treatment.

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Fig. 1:: Bar graph showing the distribution of pain scores according to the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The maximum possible score is 13 points, and the minimum is 4 points.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Following Institutional Review Board approval, 114 children with a closed extremity fracture or dislocation who received ketamine sedation to assist in closed reduction in the emergency department at our level-I trauma center were evaluated prospectively, from July 1995 to March 1997. Any child between the ages of twelve months and eleven years with a closed fracture or dislocation that necessitated a closed reduction was included in the study. An upper age-limit of eleven years was chosen because at this age the prevalence of emergence reactions begins to rise, reaching the same prevalence as that among adults by age fifteen^16,37. Children whose parents agreed to proceed with the use of ketamine after giving informed consent were included in the study cohort of consecutive patients. Patients were excluded if any of the recognized contraindications to ketamine sedation were present: pulmonary disease or upper respiratory infection, an intracranial mass or closed injury to the head, a psychiatric history, hypertension, heart disease, porphyria, glaucoma, a penetrating injury to the eye, or hyperthyroidism^15,16,32. Additionally, any child known to have ingested a meal within three hours before the planned sedation and reduction was excluded.

The study group included sixty-four male and fifty female patients with an average age of 5.3 years (range, twelve months to ten years and ten months). The average weight was 21.7 kilograms (range, 10.0 to 46.8 kilograms). Seventy-five percent (eighty-five) of the 114 injuries occurred in the upper extremity. There were fifty fractures involving both the radius and the ulna, twenty-three fractures of the distal aspect of the radius, six fractures about the elbow (one type-II supracondylar fracture, one fracture of the lateral condyle, one Monteggia fracture, two fractures of the olecranon, and one fracture of the radial neck and ulna), three dislocations of the elbow, one fracture of the proximal aspect of the humerus, one isolated ulnar fracture, and one phalangeal fracture. The remaining 25 percent (twenty-nine) of the injuries involved the lower extremity; these included fourteen femoral fractures, seven tibiofibular fractures, six tibial fractures, and two dislocations of the hip.

The guidelines of the American Academy of Pediatrics² for monitoring and equipment were strictly followed before, during, and after the administration of the ketamine. This protocol included the measurement of vital signs every five minutes and continuous monitoring of the oxygen-saturation level and heart rate. A board-certified emergency physician skilled in airway management supervised administration of the anesthetic. A registered nurse, whose sole responsibilities were to provide continuous monitoring of the patient and to help with administration of the anesthetic, was present. The emergency physician was at the bedside until the patient was successfully sedated and was noted to be stable. Subsequently, the emergency physician was immediately available in the emergency department in case of any difficulties. In addition to the pulse oximeter, equipment in the treatment room included a cardiac monitor, a positive pressure oxygen-delivery system, and suction equipment. A pediatric resuscitation cart with appropriate medications, a defibrillator, and equipment for tracheal intubation was immediately available in case of an emergency.

The ketamine was given intravenously when intravenous access was obtainable. The anesthetic was administered intravenously (at a dose of two milligrams per kilogram of body weight) in ninety-nine of the children and intramuscularly (at a dose of four milligrams per kilogram) in the other fifteen. The fracture or dislocation was reduced after the patient was observed to be adequately sedated as indicated by a trancelike state. Forty-five children were given glycopyrrolate (at a dose of two micrograms per kilogram), an antisialagogue, at the discretion of the attending emergency physician, to decrease secretions. Forty-one children received midazolam (at a dose of 0.05 milligram per kilogram) after the reduction to prevent dysphoric reactions. This tranquilizer was also given, at the discretion of the emergency physician, to the patients who were believed to be the most likely to have an emergence reaction: those at the upper age limits of this series (eight, nine, and ten years old).

A splint or cast was applied, and the adequacy of the reduction was assessed either with radiographs made in the emergency department or with portable mini-c-arm fluoroscopy. If the reduction was inadequate, the child was given more ketamine if necessary and another reduction was performed. The patients were discharged from the emergency department when the discharge criteria of the American Academy of Pediatrics² were met. These criteria include a stable airway and cardiovascular status, an age-appropriate ability to sit and talk, and a near return to the presedation level of responsiveness.

The dosage of medications, time of administration of the ketamine, and time to initiation of the fracture reduction were recorded. The patient's level of pain at the time of the procedure was assessed, according to the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS)²³, by the physician performing the reduction. This scale is a pain-scoring system based on six categories of pain-related behavior: crying, facial expression, verbalization, activity of the torso, touching responses (such as grabbing and reaching), and responses of the lower limbs (such as squirming and drawing the limbs up). The scale has a minimum possible score of 4 points and a maximum of 13 points. A score of 6 points or less essentially indicates minimal pain, while a score of 10 points or more typically reflects severe pain¹⁹.

At the first follow-up visit, parents were asked to fill out a standard questionnaire. This questionnaire was designed to determine their perception of the child's pain during the fracture reduction (if they were present during the reduction), their overall satisfaction with the procedure (including the reduction and the acceptability of the sedation), and their willingness to allow the use of ketamine again in a hypothetical scenario of a repeat fracture manipulation. Sixty-nine parents (of sixty-nine children) were present during the reduction and were able to respond to these questions. The parents were also questioned about the occurrence of any side effects (nausea, vomiting, dizziness, clumsiness, and nightmares or hallucinations) following discharge. The patients were followed until the injuries healed, and any complications of fracture management were noted.

Results

Introduction | Materials and Methods | Results | Discussion | References

The average time from the administration of the ketamine to the manipulation of the fracture or dislocation was one minute and thirty-six seconds (range, twenty seconds to five minutes) for the ninety-nine patients who received the anesthetic intravenously. For the fifteen patients who received the ketamine intramuscularly, the average was four minutes and forty-two seconds (range, sixty seconds to fifteen minutes). When the ketamine was given intravenously, the duration of the procedure (from administration of the anesthetic to complete immobilization of the limb in a cast or splint) averaged seventeen minutes and forty-eight seconds (range, five minutes to fifty-six minutes). When the ketamine was given intramuscularly, the procedure lasted an average of nineteen minutes and forty-two seconds (range, ten to fifty minutes). The high end of the ranges was for patients who underwent lengthy procedures, chiefly reduction of a femoral-shaft fracture that required subsequent application of a spica cast. The duration of the procedure did not include the time needed to make radiographs after immobilization, although the adequacy of the reduction was often assessed during the procedure with use of portable fluoroscopy. The average time to discharge from the emergency department from the initial time of the ketamine administration was eighty-four minutes (range, twenty-two to 215 minutes) for the group that received the ketamine intravenously. The average time to discharge was ninety minutes and eighteen seconds (range, sixty to 130 minutes) for the group that received the anesthetic intramuscularly.

In all 114 patients, the sedation was adequate to permit fracture reduction. The average CHEOPS score was 6.4 points (range, 5 to 10 points). Most patients (eighty-six children, 75 percent) had a score of 6 points or less, indicating minimal or no pain (Fig. 1). Only one child had a score of more than 9 points, indicating severe pain. The method of administration did not affect the pain score; the average CHEOPS score was 6.5 points in the intramuscular group and 6.3 points in the intravenous group. In thirteen children, ketamine had to be administered a second time in order to maintain adequate sedation until a splint or cast could be applied. The second dose was needed mainly for children with a femoral fracture that required the time-consuming application of a spica cast. All of the children were amnesic of the fracture reduction.

The most well known effect of ketamine, dissociative anesthesia (the cataleptic state), varied in duration and was not always noted. However, this effect averaged approximately thirty minutes, as estimated on the basis of the amount of time that elapsed before a second dose of ketamine was needed in thirteen patients.

One hundred and eleven of the fractures were deemed to have an adequate reduction. The remaining three fractures were unstable after manipulation attempts. Adequate closed reduction was obtained but could not be maintained in the emergency department despite what was believed to be good anesthesia. Reduction was lost in a ten-year-old child with a fracture of the distal aspect of the tibia and fibula; closed reduction under general anesthesia was required. It was also lost in a five-year-old child with a fracture of the radial neck and ulna, which subsequently required open reduction and intramedullary fixation of the ulna, and in an eight-year-old with a both-bone fracture of the forearm, which was treated with intramedullary fixation as well. Another twelve fractures were found to have unsatisfactory alignment and were believed to be unstable at the child's first or second follow-up visit (three to fourteen days postoperatively). Six of these fractures (five both-bone fractures of the forearm and one fracture of the distal aspect of the humerus) required either open reduction with Kirschner-wire pinning or intramedullary fixation. The other six fractures underwent repeat closed reduction with the patient under general anesthesia. All of the fractures healed.

The parents of sixty-nine children were present during the fracture reduction. They perceived their child's pain level to be low, with an average of 1.8 points on a subjective scale ranging from 1 point (no pain) to 4 points (severe pain). The parents' overall satisfaction with the procedure, including the use of ketamine, was high, with an average of 3.8 points on a scale of 1 point (not satisfied) to 4 points (extremely satisfied). All but one (99 percent) of the sixty-nine parents were pleased with the sedation and would allow ketamine to be used again in a similar hypothetical situation. The one parent without a positive response was the father of a four-year-old child who had what was believed to be a dysphoric reaction during emergence from sedation. The patient had a brief (three-minute) period of agitation, including a frightened appearance and screaming, which quickly resolved. She was given 0.2 milligram of midazolam per kilogram of body weight to assist with resolution of this reaction. An adequate fracture reduction had been obtained, and afterward the patient could not recall any of the events.

Overall, oxygen saturation averaged 98 percent, with the children's lowest levels averaging 97 percent (range, 78 to 100 percent). Two patients had saturation levels that went below 90 percent. In one patient, the level briefly decreased to 86 percent, with a spontaneous return to 95 percent. The other child had a saturation level of 78 percent that quickly responded to blow-by oxygen (oxygen that was released in front of the child's nose through a tube), with the level rising within forty seconds to 100 percent.

All of the patients remained stable hemodynamically, although mild tachycardia and a slight increase in blood pressure were common shortly after the administration of ketamine. At no time was there an episode of hypotension. Patency of the airway and independent respiration were maintained in all of the patients.

Other effects that were noted either in the emergency department following fracture reduction or at home included nausea (thirteen children, with eight having emesis), clumsiness (ten children), and dysphoria (one child, as described earlier). Clumsiness was not well defined but was characterized as minor; during the first few hours of recovery, it was evident as ataxic movements of the upper or lower extremity. No nightmares or hallucinations were noted.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Ketamine is a pharmacological analog of phencyclidine that causes dissociation between the thalamoneocortical and limbic areas of the brain and induces a cataleptic, trancelike state. It interferes with sensory perception of visual, auditory, and noxious stimuli^16,30,32. As a result, children under ketamine sedation appear to be awake, with eyes open and nystagmus evident, yet they are unresponsive to stimuli. The sedative effects of ketamine occur quickly and are short-lived, and recovery is rapid^15,16,30.

Route of Administration

Ketamine can be administered through either an intravenous or an intramuscular route^9,16,32. The intravenous route is attractive because the dose can be titrated and a smaller total dose can be given to achieve the desired effect. The onset of effects is also quicker, and recovery is more rapid^9,16. The intravenous dose of ketamine is one to two milligrams per kilogram of body weight^11,22. It should be given slowly, over a period of thirty to sixty seconds, to avoid respiratory depression.

In one study of patients who received ketamine in a pediatric emergency department, seventeen of eighteen patients who received an initial intravenous dose of 1.5 milligrams per kilogram of body weight had adequate sedation. In contrast, only six of twelve patients who received an intramuscular dose of 1.0 milligram per kilogram of body weight had adequate sedation¹¹. In the current study, all of the children who received ketamine (two milligrams per kilogram of body weight) intravenously had adequate sedation. Intramuscular administration (four milligrams per kilogram of body weight) can be used when intravenous access is unobtainable^9,15. Typically, fracture manipulation may begin one to two minutes after intravenous administration and five minutes after intramuscular administration. A repeat dose can be given ten to fifteen minutes later if the initial effect is inadequate^15,16,20. The guidelines of the American Academy of Pediatrics² for monitoring and personnel during deep sedation must be followed.

Adverse Effects

The safety and the effective use of ketamine sedation in children has been well documented in numerous studies^{7,11,12,14,15,29-31,33,34}. In 1990, Green and Johnson¹⁶ reported a meta-analysis of ninety-seven studies of ketamine sedation that included 11,589 patients. Only two children (0.017 percent) required intubation for the treatment of laryngospasm. The prevalence of emesis was 8.5 percent, but there were no cases of aspiration. Because of its unique properties and safe track record, ketamine was described by Sacchetti³⁴ as having "clearly come to the forefront as the ideal drug for emergency department use in children."

Cardiorespiratory problems occur infrequently with ketamine. Cardiovascular depression is not evident, and the normal function of the orotracheal airway, including protective reflexes, is preserved to a far greater degree than it is with other sedatives^15,16,22,32. Respiratory depression is rare and dose-related^5,22,37. Ketamine may also increase upper-airway secretions, but an antisialagogue such as atropine or glycopyrrolate can effectively minimize this effect^15,22,30,33. The gag reflex may also become somewhat depressed, and caution is recommended when a patient has a full stomach, despite the lack of documentation in the literature of aspiration occurring in these patients. We excluded children who had eaten within three hours before the planned sedation; we did not choose a longer period because of the good safety record of ketamine in children with use of this protocol^11,15. No serious adverse cardiorespiratory effects occurred in our patients, and secretions were not a problem in our study regardless of whether glycopyrrolate was administered.

Ketamine can also cause hallucinatory emergence reactions, though rarely in children who are less than ten years old^16,20. One child in the present series had a dysphoric reaction with emergence from the ketamine sedation, but this episode was short-lived and was without hallucinations. This patient did receive midazolam, which has been demonstrated to be effective in quelling emergence reactions. In older children, prophylactic administration of a benzodiazepine (midazolam) in a low dose (0.05 milligram per kilogram of body weight) can effectively prevent this side effect^22,30,33. However, the benzodiazepine may prolong recovery by delaying the metabolism of ketamine^16,32. Midazolam was given to forty-one children in our study at the discretion of the attending emergency physician. Most of these children were at the upper end of the age-range, and they received midazolam after the fracture reduction so that there would not be any contributing sedative agents that might confound the effects of the ketamine. Additionally, discharge from the hospital was not delayed by the use of midazolam.

Other adverse effects associated with ketamine include nausea, emesis, rash, increased intracranial pressure, increased blood pressure and heart rate, rigidity or hypertonicity, and random movements. Nausea was the most common side effect, occurring in 11 percent of the children in our series. Seven percent of the children had emesis but only well into the recovery phase, when they were alert. This result is similar to that in the previously mentioned pooled-data analysis of 3358 children, in which the rate of emesis was 8.5 percent¹⁶.

Despite an adequate reduction initially, 11 percent (twelve) of the fractures lost reduction and required a repeat manipulation. In retrospect, we believe that all twelve fractures underwent proper initial management with closed reduction.

Previous Studies

The use of ketamine sedation for the treatment of fractures in children has been largely ignored or at least underreported. In the extensive analysis of the literature on ketamine use by Green and Johnson¹⁶, use of the anesthetic for reduction of fractures in an outpatient setting was not specifically mentioned. However, one study⁷ in the meta-analysis did demonstrate the successful use of ketamine for multiple procedures, including those for the treatment of fractures, abscesses, and other conditions, in fifty-two patients who were five to seventy years old. In a subsequent investigation on the use of intramuscular ketamine hydrochloride sedation in the emergency department, Green et al.¹⁵ reported successful sedation in seven (6 percent) of 108 children with fractures. Additionally, in the early 1970s there were several reports in the European literature on the use of ketamine in children with fractures^8,25,27. However, to our knowledge there have been no other studies on the use of ketamine hydrochloride sedation for this purpose.

Numerous studies have assessed the efficacy of various analgesic techniques during fracture reduction in children^{6,17-19,21,26,28,35,36}. Pain in a child is often difficult to measure. A valid and reliable tool for measuring children's pain is the CHEOPS scale, as discussed earlier²³. This scale offers a simple, effective scoring method to assess pain on the basis of the child's behavior and has a high interobserver reliability of 90 to 99 percent. Several studies measuring pain during pediatric fracture reduction have used the CHEOPS scoring system^18,19,28,35. The children in our study had an average CHEOPS score of 6.4 points, indicating that they had essentially minimal or no pain during the fracture reduction. This relatively low score surpasses the CHEOPS scores reported in the previous studies.

Hennrikus et al.¹⁸ evaluated the analgesic effect of nitrous oxide in forty-nine children undergoing fracture reduction and reported an average CHEOPS score of 9.1 points. Twenty-three of the children had a CHEOPS score of 10 points or more, indicating severe pain. A subsequent study by Hennrikus et al.¹⁹ demonstrated a lower average CHEOPS score of 6.8 points in 100 children who had nitrous oxide analgesia followed by a hematoma block to facilitate fracture reduction. Notably, three of the children had no pain relief and another thirteen had pain that was observed to be severe (a CHEOPS score of at least 10 points). The average duration of inhalation of nitrous oxide until administration of the hematoma block was eight minutes, and the average duration of the entire procedure (excluding radiography) was twenty-three minutes. Varela et al.³⁵ investigated the intravenous use of meperidine and midazolam in 104 children undergoing fracture manipulation in an outpatient setting. Amnestic effects were evident in eighty-one of the eighty-seven children who were able to respond; however, the average CHEOPS score during reduction was 9.4 points, as most of the children displayed moderate signs of pain as the fracture was manipulated and most reportedly cried. The average time to manipulation of the fracture from administration of the medications was ten minutes, and the average duration of the procedure (excluding radiography) was thirty-nine minutes. Pierce and Fuchs²⁸ conducted a randomized, prospective study of thirty-four children with forearm fractures in which they compared the intravenous use of Toradol (ketorolac tromethamine) with the use of saline solution, with supplemental fentanyl given as necessary. The median CHEOPS score for both groups was 10 points.

Our results with the use of ketamine for sedation in the reduction of fractures and dislocations in children younger than eleven years of age compare favorably with the results in the previous studies. The average CHEOPS score was lower than those previously reported. The onset of effects was considerably quicker than it was with the other methods, and adequate sedation to allow fracture reduction occurred as rapidly as twenty seconds (average, one minute and thirty-six seconds) after intravenous administration. Ketamine is versatile, as it can be given through either an intravenous or an intramuscular route with essentially the same pain relief during fracture reduction. The effectiveness of ketamine during the treatment of numerous femoral fractures that required the application of a spica cast in this study shows the versatility of the anesthetic, which is effective during the treatment of both upper and lower-extremity fractures. Ketamine is also inexpensive. At a cost of two cents per milligram, a typical intravenous dose (two milligrams per kilogram of body weight) for a thirty-kilogram child costs sixty cents. The minor side effects of ketamine seen in this study were similar to those seen with intravenous sedation involving benzodiazepines or narcotics, or both.

Overall, ketamine sedation was found to facilitate the reduction of children's fractures in the emergency department at our institution under very close monitoring by trained personnel. Sedation was achieved quickly and reliably in children twelve months to ten years and ten months old. There were no major complications. Parental acceptance was strong. Ketamine appears to be a reasonable alternative method of sedation and analgesia for fracture reduction in children. Like other sedatives, ketamine can be used safely if the guidelines of the American Academy of Pediatrics² for deep sedation are adhered to. It is absolutely necessary to have one-on-one observation of the sedated child by a nurse or physician, with continuous monitoring of oxygen saturation and heart rate. Supplemental oxygen and suctioning equipment must be at the bedside, and a pediatric resuscitation cart must be immediately accessible. An individual with advanced skills in pediatric airway management must also be readily available.

The results have been so favorable with ketamine that it is now the first-line agent of sedation for children who are seen with fractures in the emergency department at our institution. The physicians and staff have become quite comfortable administering it, and we are currently using ketamine in patients as old as fourteen years. We are investigating its efficacy in these older children.

References

Introduction | Materials and Methods | Results | Discussion | References

Alexander, A. H.; Alexander, C. E.; Woodruff, R. E.; and Lichtman, D. M.: Nitrous oxide analgesia for minor orthopedic procedures. Orthopedics,6: 309-314, 1983.6309 1983

American Academy of Pediatrics Committee on Drugs:: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics,89: 1110-1115, 1992.891110 1992

Barnes, C. L.; Blasier, R. D.; and Dodge, B. M.: Intravenous regional anesthesia: a safe and cost-effective outpatient anesthetic for upper extremity fracture treatment in children. J. Pediat. Orthop.,11: 717-720, 1991.11717 1991

Bolte, R. G.; Stevens, P. M.; Scott, S. M.; and Schunk, J. E.: Mini-dose Bier block intravenous regional anesthesia in the emergency department treatment of pediatric upper-extremity injuries. 14: 534-537, 1994.14534 1994

Bourke, D. L.; Malit, L. A.; and Smith, T. C.: Respiratory interactions of ketamine and morphine. Anesthesiology,66: 153-156, 1987.66153 1987 [PubMed]

Bratt, H. D.; Eyres, R. L.; and Cole, W. G.: Randomized double-blind trial of low- and moderate-dose lidocaine regional anesthesia for forearm fractures in childhood. J. Pediat. Orthop.,16: 660-663, 1996.16660 1996

Caro, D. B.:: Trial of ketamine in an accident and emergency department. Anaesthesia,,29: 227-229, 1974.29227 1974

Caroli, G.; Lari, S.;, and Serra, G.:: La ketamina in ortopedia e traumatologia: indicazioni e limiti. Chir. org. mov.,,61: 99-104, 1972.6199 1972

Corssen, G.; Reves, J. G.; and Stanley, T. H.: Dissociative anesthesia. In Intravenous Anesthesia and Analgesia, p. 144. Philadelphia, Lea and Febiger, 1988.

Cramer, K. E.; Glasson, S.; Mencio, G.; and Green, N. E.: Reduction of forearm fractures in children using axillary block anesthesia. J. Orthop. Trauma,,9: 407-410, 1995.9407 1995

Dachs, R. J., and Innes, G. M.: Intravenous ketamine sedation of pediatric patients in the emergency department. Ann. Emerg. Med.,29: 146-150, 1997.29146 1997 [PubMed]

Dailey, R. H.; Stone, R.; and Repert, W.: Ketamine dissociative anesthesia - emergency department use in children. J. Am. Coll. Emerg. Phys.,8: 57-58, 1979.857 1979

Denton, J. S., and Manning, M. P. R. A.: Femoral nerve block for femoral shaft fractures in children: brief report. J. Bone and Joint Surg.,70-B(1): 84, 1988.70-B(1)84 1988

Epstein, F. B.: Ketamine dissociative sedation in pediatric emergency medical practice. Am. J. Emerg. Med.,11: 180-182, 1993.11180 1993 [PubMed]

Green, S. M.; Nakamura, R.; and Johnson, N. E.: Ketamine sedation for pediatric procedures: Part 1, a prospective series. Ann. Emerg. Med.,19: 1024-1032, 1990.191024 1990 [PubMed]

Green, S. M., and Johnson, N. E.: Ketamine sedation for pediatric procedures: Part 2, review and implications. Ann. Emerg. Med.,19: 1033-1046, 1990.191033 1990 [PubMed]

Gregory, P. R., and Sullivan, J. A.: Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation. J. Pediat. Orthop.,16: 187-191, 1996.16187 1996

Hennrikus, W. L.; Simpson, R. B.; Klingelberger, C. E.; and Reis, M. T.: Self-administered nitrous oxide analgesia for pediatric reductions. J. Pediat. Orthop.,14: 538-542, 1994.14538 1994

Hennrikus, W. L.; Shin, A. Y.; and Klingelberger, C. E.: Self-administered nitrous oxide and a hematoma block for analgesia in the outpatient reduction of fractures in children. J. Bone and Joint Surg.,77-A: 335-339, March 1995.77-A335 1995

Hollister, G. R., and Burn, J. M.: Side effects of ketamine in pediatric anesthesia. Anesth. and Analg.,53: 264-267, 1974.53264 1974

Juliano, P. J.; Mazur, J. M.; Cummings, R. J.; and McCluskey, W. P.: Low-dose lidocaine intravenous regional anesthesia for forearm fractures in children. J. Pediat. Orthop.,12: 633-635, 1992.12633 1992

Lowe, S., and Hershey, S.: Sedation for imaging and invasive procedures. In The Pediatric Pain Handbook, pp. 263-317. Edited by J. K. Deshpande and J. D. Tobias. St. Louis, Mosby, 1996.

McGrath, P. J., and Craig, K. D.: Developmental and psychological factors in children's pain. Pediat. Clin. North America,36: 823-836, 1989.36823 1989

Meier, D. E.; OlaOlorun, D. A.; Nkor, S. K.; Aasa, D.; and Tarpley, J. L.: Ketamine: a safe and effective anesthetic agent for children in the developing world. Pediat. Surg. Internat.,11: 370-373, 1996.11370 1996

Muncibi, S., and Santoni, R.: Utilizzazione della ketamina in ortopedia e traumatologia. Minerva Anesthesiol.,39: 370-376, 1973.39370 1973

Olney, B. W.; Lugg, P. C.; Turner, P. L.; Eyres, R. L.; and Cole, W. G.: Outpatient treatment of upper extremity injuries in childhood using intravenous regional anaesthesia. J. Pediat. Orthop.,8: 576-579, 1988.8576 1988

Pagani, I.; Ramaioli, F.; and Mapelli, A.: Prospettive sull'impiego clinico della ketamina cloridrato in ortopedia e traumatologia pediatrica. Minerva Anesthesiol.,40: 159-162, 1974.40159 1974

Pierce, M. C., and Fuchs, S.: Evaluation of ketorolac in children with forearm fractures. Acad. Emerg. Med.,4: 22-26, 1997.422 1997 [PubMed]

Proudfoot, J., and Roberts, M.: Providing safe and effective sedation and analgesia for pediatric patients. . Emerg. Med. Rep.,14: 207-217, 1993.14207 1993

Proudfoot, J.: Analgesia, anesthesia, and conscious sedation. Emerg. Med. Clin. North America,,13: 357-379, 1995.13357 1995

Pruitt, J. W.; Goldwasser, M. S.; Sabol, S. R.; and Prstojevich, S. J.: Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department. J. Oral and Maxillofac. Surg.,53: 13-17, 1995.5313 1995

Reich, D. L., and Silvay, G.: Ketamine: an update on the first twenty-five years of clinical experience. Canadian J. Anaesth.,36: 186-197, 1989.36186 1989

Sacchetti, A.; Schafermeyer, R.; Gerardi, M.; Graneto, J.; Fuerst, R. S.; Cantor, R.; Santamaria, J.; Tsai, A. K.; Dieckmann, R. A.; and Barkin, R.: Pediatric analgesia and sedation. Ann. Emerg. Med.,23: 237-250, 1994.23237 1994 [PubMed]

Sacchetti, A.: Pediatric sedation and analgesia. Emerg. Med.,27: 67-87, 1995.2767 1995

Varela, C. D.; Lorfing, K. C.; and Schmidt, T. L.: Intravenous sedation for the closed reduction of fractures in children. J. Bone and Joint Surg.,77-A: 340-345, March 1995.77-A340 1995

Wattenmaker, I.; Kasser, J. R.; and McGravey, A.: Self-administered nitrous oxide for fracture reduction in children in an emergency room setting. J. Orthop. Trauma,4: 35-38, 1990.435 1990 [PubMed]

White, P. F.; Way, W. L.; and Trevor, A. J.: Ketamine - its pharmacology and therapeutic uses. Anesthesiology,56: 119-136, 1982.56119 1982 [PubMed]

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