INTRAMUSCULAR KETAMINE, MIDAZOLAM, AND GLYCOPYRROLATE FOR PEDIATRIC SEDATION IN THE EMERGENCY DEPARTMENT

Purpose: The safety and efficacy of a new sedation technique for children with facial injuries in the emergency department were prospectively evaluated. Materials and Methods: Thirty-seven children between the ages of 12 months and 7 years old who required sedation for minor surgical procedures were administered an intramuscular injection of ketamine (3 mg/kg), midazolam (0.05 mg/kg), and glycopyrrolate (0.005 mg/kg). A second 1-mg/kg intramuscular injection of ketamine alone was given if needed. Pulse rate, cardiac rhythm, respiratory rate, oxygen saturation, side effects, and behavior were recorded. Results: Satisfactory sedation was achieved after a single injection in 32 children; five others required a second ketamine injection (1 mg/kg). Onset of anesthesia occurred within 6 minutes in 73% of the children who received one injection, and there were generally adequate working conditions for 30 minutes. The average time from initial injection to discharge was 76 minutes. Results of physiologic monitoring, behavioral ratings, and side effects are reported. Emergence delirium and hallucinations were not observed. Ketamine reliably produced dissociative anesthesia without loss of respiratory drive or protective airway tone. Midazolam reduced the incidence of ketamine-induced dysphoric reactions and muscular hypertonicity. Conclusion: The use of intramuscular ketamine, midazolam, and glycoyrrolate is a safe, effective, and practical approach to managing selected pediatric injuries in the emergency department, Advanced airway management proficiency is recommended for use of this technique.