1. Title – xxx Speaker Implementing paediatric procedural sedation in emergency departments: 2013 Ketamine Dr David Krieser FRACP Paediatric Emergency Physician, Sunshine Hospital – Western Health

2. Case An 8 year old boy –Monkey bars + Gravity FALL –Obvious left upper limb deformity –Note Past History Last intake of solids / liquids Assessment of injury – neurovascular observations Pain score and management

3. Imaging

4. Why parenteral sedation? Some procedures too painful for nitrous oxide Alternative to GA in theatre

5. Why ketamine? Predictable response compared with other agents IM and IV options Maintenance of upper airway tone and reflexes Established safety profile

6. Ketamine in your ED Ketamine and/or other parenteral agents will not be appropriate in all EDs. Each health services is responsible to determine what procedures & level of sedation in your ED If yes Policies and procedures are in place Staff trained in paediatric life support Staff trained and credentialed in use of Ketamine

7. General principles Appropriate location Sedation team: –Proceduralist + sedation doctor + sedation nurse –Senior doctor support Authorisation Fasting Consent IV agents administered by doctor only Close monitoring

8. What is ketamine? Dissociative anaesthetic –Thalamo-cortical input separated from limbic system –Profound amnesia and analgesia – “sensory isolation” –Not a dose dependent effect – a threshold is crossed Maintains upper airway tone and protective reflexes Cardio respiratory stimulant There is no reversal agent Demonstrated as safe in children in EDs

9. Indications Short very painful ED procedures or if immobilisation needed –Fracture reduction –Laceration repair (esp. facial) –Incision and drainage

10. Contraindications History of airway problems, delayed gastric emptying Very unwell URTI, acute respiratory disease –Laryngospasm Children < 1 year –Airway malposition, respiratory depression Children >12 years History of psychosis / ADHD –Emergence reaction Porphyria, thyrotoxicosis –Sympathomimetic effects increased

11. Ketamine: Dosing IV Ketamine –1 mg/kg slow IV over 1 minute –Onset 1 minute –Additional doses 0.25-0.5 mg/kg slow IV –Fast push INCREASED RISK of respiratory depression IM Ketamine –4 mg/kg –Onset 3-5 minutes –Additional doses IV 0.25 mg/kg

12. Comparing IV and IM Route of administration Intravenous (IV) Intramuscular (IM) AdvantagesEase of repeat dosing Faster recovery No IV needed Clinical onset1 minute3-5 minutes Duration of effective sedation (approx.) 15 minutes15-30 minutes Recovery (approx.)60 minutes90-150 minutes Initial dose1 mg/kg4 mg/kg Subsequent dose0.25-0.5 mg/kgInsert IV and give further doses 0.25-0.5 mg/kg Maximum dose5 mg/kg5 mg/kg (combined IM and IV)

13. Ketamine: Parent preparation Need to warn parents about ketamine effects: –For IV - tell them it usually works VERY fast “like a switch” –Eyes open: may appear awake “lights are on, nobody is home” –May move and need restraint –May adopt strange limb positions –May drool –May experience unusual sensations on recovery / agitation / nightmares –Requires observation period before discharge

14. Ketamine: Adverse effects Airway malposition Hyper-salivation Laryngospasm Respiratory depression Cardiovascular stimulation May elevate intracranial / intraocular pressure Ataxia Emergence reaction Vomiting (recovery)

15. Ketamine: Emergence reaction Hallucinations, dreaming during recovery –More frequent in adults/adolescents –Risk factors : female, rapid IV, excessive noise and stimulation, prior personality disorder –Reduce risk: suggest topics for dreaming – Ask before sedation what the child likes to do and get them to think about it dim and quiet environment

16. Let’s use ketamine Return to the Case

17. Case An 8 year old boy –Monkey bars + Gravity FALL –Obvious left upper limb deformity –Note Past History Last intake of solids / liquids Assessment of injury – neurovascular observations Pain score and management

18. Imaging

19. Staff Ketamine A doctor, credentialed for the agent used, to administer the sedation and monitor the patient AND a nurse credentialed for paediatric sedation to assist the sedation doctor. Another doctor to perform the procedure. Appropriate senior clinician available on site with the ability to immediately respond if required.

20. Ketamine: The procedure Perform only in designated area with full resuscitation equipment available IV administration only by a doctor Give slowly (over ~ 1 minute) to reduce adverse effects Continuous ECG and O 2 sat monitoring Record observations (including BP) 5 minutely

21. Ketamine: The procedure 8 year old boy with forearm fracture –Weight – 25 kg Remember topical anaesthetic for IV insertion Guided imagery; music Must prepare all equipment for reduction and plaster as per local guidelines –May include: Image Intensifier (+ radiographer), plaster of Paris, padding, sling etc Consent for sedation AND for procedure –Explain risks

22. Ketamine: The procedure Suggested prescription IV administration 1.Calculate the initial dose 2.Draw up into a 1 ml syringe 3.Transfer this (using the drawing up needle) into an appropriate size syringe and dilute with normal saline to a final concentration of 10 mg/ml 4.Administer slowly over 1 minute e.g. 20 kg Child, add 0.2 ml of ketamine to 1.8 ml normal saline = 20 mg/2 ml (10 mg/ml)

24. Ketamine: The procedure Atropine Have atropine available –Calculate the dose = 0.02 mg/kg (20 mcg/kg) Write down this calculated dose in case it is needed –Do NOT draw up –Use only if symptomatic

25. If you don’t label it… you don’t know what it is Australian Commission on Safety and Quality in Health Care National Recommendations for labeling –All injectable medicines drawn up should be labeled immediately Includes flushes, normal saline –Multiple syringes should be prepared and labeled if required –Care not to cover volume graduations with label

26. Other agents Include: –propofol –ketamine/propofol (Ketofol) –midazolam (unreliable) –chloral hydrate (non-painful procedures) Same principles of safe practice apply

27. Summary: Key elements Procedure can occur in your ED Child is suitable to have ketamine Child and parent preparation Standardised processes including –Consent –Drug management –Documentation –Monitoring –Discharge Credentialing of staff Recognition and management of adverse events

28. Questions