Objective-To compare the eYcacy of oral ketamine (10 mg/kg) with oral midazolam (0.7 mg/kg) in providing sedation for suturing of lacerations. Method-Prospective, randomised, double blinded trial with consecutive, concealed recruitment of 59 children aged 1 to 7 with wounds requiring local anaesthetic (LA) injection or topical LA with an anxiety score greater than one. Results-Tolerance to LA injection was better with ketamine (p=0.029) and tolerance to procedure after LA injection showed a trend towards being improved with ketamine (p=0.067). There was no diVerence in tolerance to LA application or procedure in children receiving topical LA. Time to reach a sedation score of less than four was faster with ketamine (medians 20 versus 43 minutes, p=0.001) but times from dosing to discharge (medians 105 and 110 minutes) were similar. Inconsolable agitation was reported with midazolam in six cases. Dysphoria was not noted with ketamine. Vomiting was more common with ketamine but not significantly so (six versus two, p = 0.14). Oxygen desaturations were noted in both groups. Ataxia after discharge was seen in four patients, two in each group. Thirty six per cent of children showed new behavioural disturbances in the two weeks after discharge, more commonly in the midazolam group (p=0.048). Conclusions-At these doses tolerance to LA injection was better in children receiving ketamine, with fewer behavioural changes noted in the first two weeks. Midazolam at this dose caused dysphoric reactions, which may have aVected the results. Continuous pulse oximetry monitoring is required when using these drugs. Vomiting and prolonged ataxia occurred in a few patients.

Objective-To offer clear guidance on the anaesthetic management of Colles' fractures in the accident and emergency (A&E) department in the light of the conflict between existing reports and current trends, and to address the issue of alkalinisation of haematoma blocks. Methods-This was a two centre, prospective, randomised clinical trial with consecutive recruitment ofadult patients with Colles' fractures requiring manipulation to receive either Bier's block or haematoma block. There was subsequent blinded randomisation to alkalinised or non-alkalinised haematoma block. Results-72 patients were recruited into the Bier's block group, and 70 into the haematoma block group. Bier's block was less painfil to give than the haematoma block (median pain score 2.8 v 5.3; P << 0.001), and fracture manipulation was also less painfiu in the Bier's block group (median pain score 1.5 v 3.0; P < 0.01). There was no significant difference in overall A&E transit time between the two groups. There was better initial radiological outcome in terms of dorsal angulation in the Bier's block group (-3.60 v 2.10; P = 0.003). More remanipulations were required in the haematoma block group (17/70 v 4172; P = 0.003). There was a trend towards decreased pain on administration of the alkalinised haematoma block when compared with non-alkalinised haematoma block, but this did not reach significance. There was no difference in pain score on fracture manipulation. There were no complications in either group. Conclusions-Bier's block is superior to haematoma block in terms of efficacy, radiological result, and remanipulation rate; transit times are equal, both procedures are practical in the A&E environment, and there were no complications. Bier's block is the anaesthetic management of choice for Colles' fractures requiring manipulation within the A&E department. (Accid Emerg Med 1997;14:352-356) Keywords: Colles' fracture; Bier's block; haematoma block; alkalinisation Colles' fractures are manipulated using a variety of anaesthetic techniques within the accident and emergency (A&E) department. A survey of the larger A&E departments in 19941 showed that haematoma block had increased dramatically in popularity over the preceding five years, largely at the expense of the general anaesthetic, accounting for 33% of all reductions; a further 33% were performed under Bier's block, a proportion which had remained unchanged over the preceding five years.2 This move away from the use of a general anaesthetic may have been driven by the cost and resource implications of not having to admit patients and prepare them for a formal theatre procedure.It is less clear why the haematoma block, rather than Bier's block, has filled the space left by the general anaesthetic when one reviews the available reports. Case3 retrospectively compared haematoma block, Bier's block, and general anaesthetic in 136 patients and found that there was no difference in the remanipulation rates between the three methods of anaesthesia. No other outcome measures were mea...

Objective: To evaluate the tolerability and efficacy of intranasal fentanyl analgesia for children. Methods: A prospective, open‐label, two‐arm pilot study was conducted. Children, aged 3 to 10 years, with clinical limb fractures were randomized to receive 1 μg/kg intranasal fentanyl via nasal spray or 0.2 mg/kg intramuscular morphine. Tolerance to administration, pain scores, rescue analgesia, adverse events and physiological data were recorded at intervals over 30 min. Results: Forty‐seven children were recruited to the study. Tolerance to administration was better for intranasal fentanyl compared with intramuscular morphine (median scores 1 vs 2; P < 0.001). Pain scores over the trial period were similar in both groups. One child receiving intranasal fentanyl required rescue analgesia. No significant adverse effects were noted. Conclusions: Intranasal fentanyl provides effective paediatric analgesia comparable to intramuscular morphine and is better tolerated. A larger study is needed to determine dose range and confirm safety.

Excessive tracheal tube cuff pressures were demonstrated in the majority of patients intubated both in the prehospital setting and ED. This is in keeping with existing evidence. Early measurement and adjustment of cuff pressures is recommended for those patients who require ongoing care.

Objectives: The aim of the present study was to document the use of sedation in paediatric patients in emergency departments within Australia and New Zealand. Methods: A questionnaire was sent to 54 emergency departments throughout Australia and New Zealand. Results: A total of 45 departments (83%) responded to the survey. Because the adult departments (n = 5) reported few paediatric attendances, they were not included in the analysis. Thirty‐nine of 40 departments (97.5%) reported using sedation in children. Midazolam was used most frequently (77%) for sedation. There was marked variation in the route of delivery and the dose of midazolam used. Ketamine was reported as the most efficacious agent used, but it was used only in 12% of cases. Formal guidelines existed in all paediatric departments but only in 58% of mixed departments, and formal discharge criteria were used in only 52% of all departments. The use of topical anaesthesia in wound closure was reported in only 30% of departments. Conclusions: There exists wide variation in practice regarding the use of sedation in children in emergency departments throughout Australia and New Zealand. Thus, the development of adequate guidelines, including discharge instructions and the use of topical agents, will improve sedation for children.