Ketamine is still safe without concurrent midazolam and atropine for pediatric procedures in the emergency department

Abstract

Aim. Although the safety of ketamine for pediatric procedural sedation and analgesia is well established, use of concurrent benzodiazepines and atropine to diminish the adverse events is still controversial. We wanted to determine whether the adjunctive midazolam reduces the recovery agitation and to compare the incidence of adverse events with those reported in the literature. In particular, we wanted to assess whether adjunctive atropine can diminish salivation in order not to cause compromise of the airways. Methods. This prospective study was conducted in the Emergency Department of Akdeniz University Hospital. A detailed conscious sedation protocol was developed, and emergency physicians and nurses were educated regarding its contents. All patients who underwent procedural sedation and analgesia were evaluated by using a standardized conscious sedation form. Patients presenting with any trauma who were aged 15 or younger and requiring sedation and analgesia were evaluated. Results. During a 31-month period, 141 children received ketamine for procedural sedation and analgesia. The most frequent indication for sedation and analgesia was laceration repair (85.8%). Single dose intramuscular ketamine injection was adequate to complete the procedure in 55 patients. Concurrent midazolam was administered in 50 patients and concurrent atropine in six patients. Agitation on recovery was noted in 12.8% patients; however no statistically significant difference was determined between patients who received only ketamine and those who received ketamine plus midazolam. Other adverse effects included hypersalivation (15.6%), nausea (10.6%) and vomiting (6.4%). Adverse events affecting the respiratory system were few and none required intubation. No untoward cardiopulmonary adverse events were noted. Conclusions. Unless contraindicated, ketamine should be the drug of choice for pediatric patients by administering it first intramuscularly then intravenously when needed. Concurrent use of benzodiazepine and atropine appears not to diminish adverse effects.