An alternative to "brutacaine": a comparison of low dose intramuscular ketamine with intranasal midazolam in children before suturing.

Abstract

Objective-To compare the use oflow dose intramuscular ketamine with high dose intranasal midazolam in children before suturing. Methods-Altogether 102 children with simple wounds between 1 and 7 years old were allocated to the two study groups. Results-Two children were excluded from the study because of deviation from the agreed protocol. The 50 children in the ketamine group were less likely to cry or need to be restrained during the procedure than those in the midazolam group (p<0.0l).The median oxygen saturation was 97% in both groups. There was no difference in the recovery behaviour and the range oftime at which children were ready for discharge, although the median time for the latter was shorter in the midazolam group (75 v 82 minutes). Vomiting occurred in nine of the ketamine and four of the midazolam group. After discharge both groups had an unsteady gait (73% v 71%) which usually resolved within two hours. Conclusion-Intranasal midazolam (0.5 mg/kg) effectively sedated the children in that none could remember the suturing. However a significant number still had to be restrained (86% v 14%). Intramuscular ketamine (2.5 mg/kg) produced dissociative anaesthesia in the majority of cases and was the preferred drug of nurse, doctor, and parent.(7Accid Emerg Med 1998;15:231-236)

Clinical practice guideline for emergency department ketamine dissociative sedation in children

“…It appears to be a separate entity from the ketaminespecific hallucinatory reactions 30 because it occurs at a similar frequency as with midazolam alone. 16,20,102 A recent study demonstrated that recovery agitation is not clinically significant in children. 30 Physicians graded ketamine recovery agitation using a 100-mm visual analog scale, with the median rating being 5 mm, low enough to lack clinical significance.…”

A double-blind, randomised, placebo-controlled trial of oral midazolam plus oral ketamine for sedation of children during laceration repair

“…The optimal oral dosing for ketamine that provides appropriate sedation with minimal or no adverse effects has not been determined yet. Common known adverse effects of ketamine include vomiting, transient ataxia and drowsiness 10 – 13. Oxygen desaturation is a rare complication described only with intravenous or intramuscular delivery 12.…”

Procedural Sedation for Children With Special Health Care Needs

“…Nasal transmucosal administration of drugs entails injection of a liquid vehicle into a child's nostril, a procedure most children resist vehemently. [16][17][18] Intramuscular administration of medications is more reliable than either oral or rectal routes, but it still presents a titration problem. Physical obstacles may be considerable with this route if a second dose is required in a developmentally or behaviorally challenged child beyond the first decade of life.…”