Dissociation – trance-like state with eyes open but not responding
Catalepsy – normal or slightly increased muscle tone maintained
Analgesia – excellent analgesia is typical
Amnesia – usually total
Airway reflexes maintained
Cardiovascular state – blood pressure and heart rate increase slightly
Nystagmus is typical – usually horizontal; eyes remain open and glazed
Who can perform it?
Senior medical staff (ST3+)
Must have done at least 6 months of anaesthetics/ICU
Familiar with giving ketamine, particularly in under 5s
Must have at least 3 staff members– someone to perform sedation, someone to perform procedure, someone to monitor the patient
Department must be safe – Senior ED Clinician in charge (Consultant of Senior Registrar when Consultant not present in department has final say over if it is appropriate to perform at any given time.
Where should it be performed?
Full monitoring – 3 lead ECG, sats probe, BP cuff, CO2 monitoring
Child >1 years old
Procedures such as:
Removal of foreign body
Chest drain placement
Any patient who requires to go to theatre for management of their condition
Any risk of difficult airway eg. abnormal airway anatomy
Allergy/serious adverse reaction to ketamine
Procedure in mouth or throat
Significant medical problems including:
Active respiratory infection/active acute asthma (high risk of laryngospasm)
Obstructive sleep apnoea
Moderate to severe gastro-oesophageal reflux disease
Psychological problems eg. severe behavioural or cognitive impairment or previous psychosis
Poorly controlled epilepsy
Significant cardiac disease
Chronic Intracranial pathology
For an emergency procedure in a child or young person who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation. Consider discussing this child with an anaesthetist.
Apply the 2-4-6 fasting rule for ketamine sedation in the ED if safe and appropriate for the procedure to wait for this:
2 hours for clear fluids
4 hours for breast milk
6 hours for solids and formula milk
Parent and child (if appropriate) should be consented appropriately
Risks and benefits along with potential side effects should be explained
Mild side effects
Mild agitation (20%)
Hypersalivation and lacrimation (<10%)
Involuntary movements / ataxia (5%)
Vomiting 5-10% of children will vomit in recovery period
Can give ondansetron (0.1mg/kg) in intractable vomiting
Transient rash 10%
More serious complications
Apnoea (0.3%) – Give IV ketamine slowly over 1 minute to avoid this
Airway misalignment/noisy breathing (<1%) -Basic airway manoeuvres usually enough to resolve this
Basic airway manoeuvres
BVM if needed
Ask for help early
May require RSI (rarely 0.02%)
Emergence Phenomena (1.6% <10 years old, commoner as gets older)
Calm environment before procedure and as awakening
In very severe cases can give benzodiazepines (eg. 0.05-0.1mg/kg midazolam)
1mg/kg – give over 1 minute
Supplemental dose (eg. in longer procedure if needed) – 0.5mg/kg
Initial dose and potential supplemental dose should be drawn up into separate syringes to minimise error
Calculate doses of emergency drugs that may be needed and ensure access to them
Speed of action of ketamine
Clinical onset (approximately) 1 minute
Effective sedation 10-20 minutes
Time to discharge (average) 90 minutes
Post sedation care
Observe for 1-2 hours until:
Conscious and responding appropriately
Able to walk unassisted (older children)
Vital signs are within normal limits
Respiratory status not compromised
Pain and discomfort addressed
No food or drink for 2 hours after discharge (risk of nausea and vomiting)
Supervise child closely for 24 hours (risk of ataxia and falls), no driving for older children
Although COVID-19 seems a benign disease in almost all children there are increasing evidence (however rare) of a “Paediatric multisystem inflammatory syndrome”. This is a RARE and newly emerging condition and there are many questions still e.g. It is currently unclear if it is directly related to the COVID-19 pandemic.
Case definition (RCPCH)
A child presenting with persistent fever, inflammation (neutrophilia, elevated CRP and lymphopaenia) and evidence of single or multi-organ dysfunction (shock, cardiac, respiratory, renal, gastrointestinal or neurological disorder). This may include children fulfilling full or partial criteria for Kawasaki disease.
Exclusion of any other microbial cause, including bacterial sepsis, staphylococcal or streptococcal shock syndromes, infections associated with myocarditis such as enterovirus (waiting for results of these investigations should not delay seeking expert advice).
SARS-CoV-2 PCR testing may be positive or negative
Parents who have experienced a sudden and unexpected death of a baby or child often feel anxious when they have another baby. CONI is a programme working with local public healthcare providers to facilitate a service for bereaved parents to help with the anxieties around another baby.
In our trust we don’t have paediatric critical care beds. However, in our region we use EMBRACE (a paediatric critical care transport team), who can transfer critically ill children to specialist centers (in or out of region).
Severe pain is the most common reason that patients with sickle cell, will attend the ED. The pain can be agonising (and often underestimated by us), we need to act fast to help ease the symptoms Read more
Unfortunately under 1 year olds are at a higher risk of NAI and this needs to be considered in ALL presentations. But remember if the child can’t Crawl/Stand/Cruise/Walk they shouldn’t injure themselves.