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Three Part Question

In [children needing painful procedures in the emergency department] is [ midazolam or ketamine] [ safer and more effective at achieving conscious sedation]?

Clinical Scenario

A mother brings her five year old son to the Emergency Department (ED) with a deep scalp laceration having fallen onto the corner of a coffee table. The wound requires sutures. For various reasons the option for procedural sedation in this department is limited to midazolam. Due to your past experience, you are more comfortable using ketamine. Although there is a large amount of data in the Emergency literature to show efficacy and safety for both agents, you are not aware of direct comparisons to back your preference for ketamine in children in the ED setting.

Search Strategy

Medline 1960- April 2007 using the OVID interface
The Cochrane Library Issue 2 2007
Medline 1960- April 2007 using the OVID interface: (exp ketamine/or ketamine .mp.) and (exp midazolam/or midazolam.mp.) and (exp child/ or "children".mp. or exp pediatrics/ or "pediatric". mp.). Limit to human and English language.
The Cochrane Library Issue 2 2007: MeSH descriptor Ketamine explode all trees AND MeSH descriptor Midazolam explode all trees AND (emergency department):ti,ab,kw 7 papers none relevant

Search Outcome

Of the 203 papers found in Medline 199 were found to be irrelevant or of insufficient quality for inclusion. Of 7 papers found in Cochrane none were relevant. The remaining 4 papers are shown in the table below

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
McGlone et al, 1998, UK	102 children (1-7 yr) Divided into either midazolam(0.5mg/kg nasal) or ketamine (2.5mg/kg IM)	Prospective 'allocation'	Behaviour before, during and after procedure	Significantly less restraint required in ketamine group (P<0.01)	? randomised Two different routes of administration, uncertain final bioavailability of intra-nasal route. Small numbers Atropine added to ketamine group
			Vomiting before and after discharge	Ketamine caused more vomiting during recovery (P=0.012)
			Time to discharge	Midazolam children discharge 7 minutes earlier
			Parental and nursing satisfaction	Ketamine significantly preferred (P=0.018)
Everitt et al, 2002, Australasia	54 Australasian Emergency Departments Ketamine 12% Midazolam 77%	Survey of agents used and ED physicians 45 of 54 surveyed departments responded	Linear analogue depiction of perceived efficacy of sedation	IV Ketamine 14% better sedation than midazolam	One respondent per ED Open to responder bias Not patient focused No standard doses Not limited to ketamine & midazolam alone
Roback et al, 2005, USA	2,500 consecutive children (median age 6.7 years) receiving IV or IM procedural sedation Ketamine 59% Midazolam/Ketamine 12% Midazolam 10.4%	Prospective data base Retrospectively analysed	Respiratory complications Apnea/Larygospasm/desaturation	Ketamine 6.1% Ketamine/midazolam 10% Midazolam 5.8%	Not randomised not blinded. Multiple drugs combinations. ? standardised doses Glycopyrolate was given to all who had ketamine. ?mandatory reporting
			Vomiting	Ketamine 10.1% Ketamine/midazolam 5.4% Midazolam 0.8%
Sacchetti et al, 2007, USA	226 children aged less than 13 yrs Ketamine 60% Midazolam 28% Across 14 community EDs.	Prospective data base	Adverse events	Nil recorded for both drugs	Data base 'self reported', ?reliability Low rate of respiratory events reported

Comment(s)

The available comparative studies involved multiple agents and combinations, routes of administration and doses. No head to head trials of iv ketamine vs iv midazolam for procedural sedation in children in the emergency setting could be found. Secondary findings show that satisfaction of parents and physicians was greater with ketamine and that physicians felt it was safer.

Clinical Bottom Line

Ketamine and midazolam have similar safety profiles in the emergency setting for children. Ketamine causes more vomiting but appears to be the preferred agent for most parents and many ED physicians.

References

1. McGlone RG, Ranasinge S, Durham S. An alternative to "brutacaine": a comparison of low dose intramuscular ketamine with intranasal midazolam in children before suturing. Emerg Med J 1998;15:231-6.
2. Everitt I, Younge P, Barnett P. Paediatric sedation in emergency departments: what is our practice? Emerg Med 2002:14, 62-66.
3. Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parental drugs. Acad Emerg Med 2005;12:508-13.
4. Sacchetti A, Stander E, Ferguson N, Maniar G, Valko P. Pediatric Procedural Sedation in the Community Emergency Department: results from the ProSCED registry. Pediatr Emerg Care 2007;23:218-22.