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Paediatric analgesia and sedation
A 4 year old child presented to our ED with a grossly deformed right fore arm. He was crying incosolably and refused to take any oral analgesia (agitated). He also wasn't aware of his problem and was moving his broken arm. Needless to say this compounded the problem. Obviously the parents were even more distresed.

As he was not taking any analgesia by mouth, I ended up giving him lots of vocal anaesthesia (storytelling!!!) and subsequently 'intra-nasal' diamorph. This also allowed us to splint the arm in plaster. The parents too seemed a bit relieved.

What do members feel about analgesia and departmental procedural sedation of children. Do you use any other agents (like buccal midazolam, IV Ketamine etc)??
IM Ketamine would probably be a good option in this case. It is safe and effective and is the recommended policy in our department. we also use it for procedures like would repair/exploration where the alternative would have been a GA.
What about IV Ketamine? (though the idea of getting a cannula into an already screaming child would make me extremely suicidal!!!)
Is IM Ketamine better than IV in paediatric sedation. Are the effects as predictable as IV form?
Do you give Atropine along with Ketamine for children as per your policy?
IM Ketamine is safe and predictable which is a bonus for children, the other advantage being that one doesn't have to cannulate! Atropine is recommended (0.01/kg) to reduce salivation reactions, but I have seen colleagues who haven't used atropine.
I myself have used IM Ketamine for children for a variety of procedures for the past 8 yrs or so and am happy with it; so are my colleagues in my department. It saves us transferring the patient to a specialist just for GA and the patient is sorted within a single episode.
Intra-nasal Midazolam wud also work very well...in such cases
one more question which I had wanted to ask regarding the use of IM/IV ketamine which is alwys a fantastic drug was...as the child was agitated pre-sedation...did the child have a screaming and agitated "emergence phenomenon"when he was coming out frm the ketamine effect??
Don't know about others, but I haven't noticed any 'emergence phenomenon' in the paed cases where I used Ketamine.... or does it mean that I haven't used it in enough??

Lot of studies do also mention that this phenomenon is very uncommon in the paed group...
agree with maroju.
have used IM ketamine, and IV ketamine both.
and no there havent been any major emergence phenomena.
except in one kid... who couldnt stop staring at me..
but no it was all okay.
though i do keep an IV line on hand at all times after administration of IM ketamine, for the just in case probs.
And leave footprints in the sands of time.......
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