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Three Part Question

[In a child with an isolated fracture requiring closed reduction] is [ketamine sedation versus general anaesthetic as effective] at [analgesia, sedation, and remanipulation].

Clinical Scenario

An eight year old child presented to the Emergency Departemnt with a greenstick fracture of the right dital radius and ulnar with approximately 35 degrees angulation. The child is fit and well, no past medical history, no regular medication or allergies, and last ate and drank four hours ago.
Current policy is to refer the child to orthopaedics for MUA, but a colleague wonders if the manipulation could be performed in the Emergency Department using ketamine sedation.

Search Strategy

Medline 1950-October 2008 using the OVID interface.
PubMed
[exp.fracture, closed OR fracture, reduction] AND [exp. ketamine OR exp. conscious sedation OR exp. anaesthesia, general, OR exp. propofol] AND [exp. emergency departemnt, hospital] LIMIT to human, English, and children aged 0-18 years.

Search Outcome

The search strategy found three papers all were relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kennedy RM, Porter FL, Miller JP, Jaffe DM October 1998 Missouri, USA	260 patients aged 5-15 years, block randomized in two groups	Partially blinded PRCT	efficacy using the Observational Scale of Behavioural Distress - Revised (OSBD-R)	Lower distress scores and parental ratings of pain and anxiety using ketamine/midazolam	Health care providers and families not blinded therefore scoring open to bias (FAS/VAS). Dose of each sedatative drug not standardized. Unclear if department acuity or business affected recruitment. Although OSBD-R scorers blinded, the characteristic faces of children receiving ketamine may have led to bias.
McCarty, EC et al July 2000 Tennessee, USA	114 consecutive patients with closed fractures or dislocations	prospective cohort	pain at time of proceedure using CHEOPS (Childrens Hospital of Eastern Ontario Pain Scale)	Average score 6.4 (minimal or no pain) during fracture reduction. Adequate fracture reduction in 111 patients.	Pain scoring subject to bias by individual practitioners performing proceedure. No control group. Sample size not calculated.
Godambe SA et al July 2003 Tennessee, USA	113 patients aged 3-18 years	Prospective partially blinded RCT	Recovery times. Procedural distress measured by OSBD-R	OSBD-R scores lower for the ketamine group (statistically significant).Recovery time significantly lower in the propofol group. Ketamine had significantly fewer desaturation events and fewer required airway maneuvers.	Pain score not validated. Recuitment variable depending how busy the ED was at the time of presentation. Poor methods of randomization. Dose of sedative drugs given not standardized. Partially blinded. Study not powered for comparision of adverse events.

Comment(s)

Search strategies have found few well designed RCT's comparing ketamine with other drugs for sedating children requiring fracture manipulation. Different criteria were used for assessing levels of analgesia, and validated pain scores were not always used. Although it appears that ketamine is a superior agent for fracture reduction in children, further comparative studies are required including the use of ketamine without midazolam.

Clinical Bottom Line

Ketamine may be considered for sedation of children requiring fracture maniputation, however further high quality RCT's are required.

References

1. Kennedy RM, Porter FL, Miller JP, Jaffe DM Comparison of fentanyl/midazolam with ketamine/midazolam for paediatric orthopedic emergencies Paediatrics October 4 1998; Vol 102, No 4: 956-963
2. McCarty, EC et al Ketamine sedation for the reduction of childrens fractures in the emergency department Journal of bone and joint surgery July 2000; 82 (7): 912-918
3. Godambe SA, Elliot V, Matheny D, Pershad J Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopaedic procedural sedation in a paediatric emergency department Paediatrics July 2003; Vol 122: 116-123