Article of the Month: June 2015

Disel NR, Yilmaz HL, Sertdemir Y, et al. Etomidate versus ketamine: Effective use in emergency procedural sedation for pediatric orthopedic injuries. Ped Emerg Care; 2015 (ePub ahead of print).

Main Points:

• This study was a single-blinded randomized, controlled trial of etomidate + fentanyl versus ketamine sedation in 44 children aged 7-18 years old with orthopedic injuries.
• The mean amount of drugs used to achieve sedation were etomidate 0.25 mg/kg + fentanyl 1.3 micrograms/kg v. ketamine 1.25 mg/kg
• Mean induction time was 4.3 minutes for etomidate versus 2.2 minutes for ketamine.
• There was no difference between groups for recovery times, adverse events, or post-sedation observation times.
• 14 patients (32%) reported adverse events, but there were no serious adverse events. Adverse events seen were nausea, urticarial, hypoxemia, myoclonus, excessive secretions and pain at injection site.
• Etomidate+fentanyl led to less recall of pain than ketamine
• One child in the etomidate+fentanyl group was admitted after failed reduction.

Article of the Month: April 2015

Graudins A, Meek R, Egerton-Warburton D, et al. The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A Randomized Controlled Trial Comparing Intranasal Ketamine and Fentanyl for the Relief of Moderate to Severe Pain in Children With Limb Injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1.

Main Points:

• Double-blind randomized controlled trial comparing intranasal ketamine (1 mg/kg) and intranasal fentanyl (1.5 mcg/kg) in 80 patients with isolated limb injury and triage pain score of 6/10 or more; primary outcome was reduction of reported pain at 30 minutes post medication.
• Patients were 3-13 years old, <50 kg, and had isolated limb injury without other signs of trauma.
• There were similarities in pain reduction (15, 30 and 60 minutes post-medication), degree of sedation, subjective improvement, and satisfaction between both groups.
• There were significantly more adverse effects in the ketamine group compared to the fentanyl group. 15 patients in the fentanyl group reported 24 adverse effects, while 28 patients in the ketamine group reported 67 adverse events, including “dizziness” (most common), “bad taste in mouth,” and “drowsiness”.
• However, adverse effects were well tolerated. There were no reported cases of emergence reactions or hallucinations.