The Lancaster experience of 2.0 to 2.5 mg/kg intramuscular ketamine for paediatric sedation: 501 cases and analysis.

OBJECTIVES: To report the experience of using intramuscular ketamine 2.0 or 2.5 mg/kg for minor painful procedures in children in a medium sized district general hospital accident and emergency department. To demonstrate the safety and acceptability of ketamine and determine if the incidence of adverse effects is related to dose or other variables. METHODS: Prospective data collection and analysis using Statsdirect and SPSS software. RESULTS: 501 consecutive cases were collected from August 1996 to April 2002. A total of 310 children received 2.0 mg/kg and 191 received 2.5 mg/kg. Twenty six received a second dose. In seven cases oxygen saturation fell below 93%, three of these fell below 90%. There was one case of laryngospasm. Eight cases received airway suctioning, five of these were mouth or lip wounds. Seventeen per cent vomited in recovery or at home for which one child required admission. Muscle hypertonicity was observed in 6.8%, disturbed sleep or nightmares in 2%. The median time to discharge was 85 minutes. Ninety seven per cent of parents' experiences were "the same as" or "better than" expected. No children suffered any lasting or troublesome complications. CONCLUSIONS: 2.0 - 2.5 mg/kg intramuscular ketamine sedation is a safe and acceptable technique when used within a defined protocol. Lower dose ketamine (2 mg/kg) warrants further study in view of potentially less airway complications and quicker discharge times than previously reported.

A comparison of intramuscular ketamine with high dose intramuscular midazolam with and without intranasal flumazenil in children before suturing.

OBJECTIVES: (a) To compare the use of high dose intramuscular midazolam with and without intranasal flumazenil in children after suturing. (b) To compare the use of high dose intramuscular midazolam with low dose intramuscular ketamine in children before suturing. METHODS: 87 children, aged between 1 and 7 years, presenting with simple wounds needing sedation, were studied. Children considered combative (n=47) were given ketamine (2.5 mg/kg intramuscularly). The remaining 40 children were given midazolam (0.4 mg/kg intramuscularly) with and without flumazenil (25 microg/kg, intranasally). RESULTS: The median oxygen saturation was 97% in both midazolam groups. Flumazenil significantly reduced the amount of agitation during recovery (p=0.048) and also the time at which children were ready for discharge (median 55 versus 95 minutes, p value <0.001). After discharge both midazolam groups had an unsteady gait (75%) and there was no significant difference in the duration. As expected because of the deliberate selection of combative children into the ketamine group, the pre-sedation behaviour was slightly more disturbed compared with the midazolam group (p=0.10). However, the ketamine group was less agitated during local anaesthetic and suturing p<0.001. CONCLUSION: Intramuscular midazolam (0.4 mg/kg) did not effectively sedate the children, in that a significant number still had to be restrained. However, none could remember the suturing. Intranasal flumazenil seems to be effective in shortening the time to discharge. If midazolam is to be used then a dose high enough to produce full amnesia should be used, there seems to be no advantage in increasing the dose further. Low dose intramuscular ketamine remains the drug of choice.

An alternative to "brutacaine": a comparison of low dose intramuscular ketamine with intranasal midazolam in children before suturing.

OBJECTIVE: To compare the use of low dose intramuscular ketamine with high dose intranasal midazolam in children before suturing. METHODS: Altogether 102 children with simple wounds between 1 and 7 years old were allocated to the two study groups. RESULTS: Two children were excluded from the study because of deviation from the agreed protocol. The 50 children in the ketamine group were less likely to cry or need to be restrained during the procedure than those in the midazolam group (p < 0.01). The median oxygen saturation was 97% in both groups. There was no difference in the recovery behaviour and the range of time at which children were ready for discharge, although the median time for the latter was shorter in the midazolam group (75 v 82 minutes). Vomiting occurred in nine of the ketamine and four of the midazolam group. After discharge both groups had an unsteady gait (73% v 71%) which usually resolved within two hours. CONCLUSION: Intranasal midazolam (0.5 mg/kg) effectively sedated the children in that none could remember the suturing. However a significant number still had to be restrained (86% v 14%). Intramuscular ketamine (2.5 mg/kg) produced dissociative anaesthesia in the majority of cases and was the preferred drug of nurse, doctor, and parent.

Study of aeroball injuries.

OBJECTIVE: To present the risks of aeroball, a new sport played by either two or four players on a trampoline court surrounded by specially constructed fabric walls, and to propose ways to increase awareness and reduce the incidence of injury, in particular, ankle injury. METHOD: A study was carried out to document the nature of aeroball related incidents, between 1991 and 1995, at Lancaster University Sports Centre. Lace-up ankle supports were introduced in April 1992, and their effect on the incidence of ankle injury was recorded. RESULTS: The lower limb received most injuries (90%), followed by the upper limb (6%), then the face (3%) and cervical spine (1%). The most common category of injuries was sprains (83%), followed by fractures (8%), contusions (5%), and dislocations (4%). The most common site of injury was the ankle (73%). It is during doubles play that injury is most likely to occur. Since the introduction of ankle supports, there has been a gradual decline in the incidence of ankle injury, 31 in 1991 to nine in 1995. CONCLUSION: Aeroball has become a popular sport, but it is not without risks. Leaflets have been produced to promote the objectives, rules, and safety of the game. Trained full-time staff should be present to explain the nature of the game. The use of prophylactic ankle stabilisers in aeroball is strongly recommended.

Laparoscopic training for theatre personnel.

Many theatre units have begun to liaise with surgeons and with manufacturers to train theatre personnel to work as part of a team carrying out laparoscopic surgery. Indeed, some courses are already well established. This short article describes the experience of one theatre unit of such a training programme.

Reducing the pain of intradermal lignocaine injection by pH buffering.

The effect of pH on the pain of administration and efficacy of 1% lignocaine was investigated in a prospective, double-blind, randomized study of 20 adult volunteers. Onset and spread of anaesthesia by intra-dermal injection were not altered, but there was a significant reduction in pain scores with a higher pH. Overall, pain scores appear to be more dependent on the speed of injection rather than alteration of pH.

Use of Ames SG10 Urine Dipstick for diagnosis of abdominal pain in the accident and emergency department.

In a prospective study of 1112 patients presenting to the Accident and Emergency Department with abdominal pain; the SG10 Ames Urine Dipsticks were shown to be a valuable screening test for the detection of infected urine. Introducing this technique would reduce by at least 37% the number of urgent requests for microscopy of midstream urines (MSUs). Dipstick testing however was not a reliable screening test for microscopic haematuria.

Do we need to cross-match blood in closed fractures of the shaft of the femur?

A total of 50 patients with isolated closed fractures of the shaft of the femur are presented. Eleven per cent of the blood specimens were merely grouped and saved on arrival, and the remaining 39 (78 per cent) were crossmatched between 2 and 6 units. Overall, 138 units of blood were crossmatched and only 16 units were used (11.5 per cent), none of them actually in the accident and emergency department. We can find no record of blood being given for resuscitation. The use of blood appeared to depend on the occurrence and timing of operation. We suggest that local policy for crossmatching blood for such patients takes into account the orthopaedic surgical plan, but that the routine instruction to cross-match blood on arrival be abandoned.

Hypnozoites in Bradford.

We present two paediatric cases of a condition that should be considered when a child of an immigrant family presents to the A&E department with a pyrexia with no obvious focus of infection.

The use of muscle relaxant to supplement local anaesthetics for Bier's blocks.

In searching for the 'ideal' muscle relaxant for use with intravenous regional anaesthesia, muscle relaxation was assessed with and without the addition of Atracurium to Bier's Block in four volunteers. This was followed by a clinical study of 36 patients with wrist fractures to confirm the drug's safety and examine the possible clinical advantages of using a muscle relaxant. The addition of 2 mg of Atracurium to the Bier's Block improved the ease of reduction (P less than 0.025) and the quality of analgesia (P less than 0.05) (Mann-Whitney U test). The authors conclude that the addition of Atracurium to a Bier's Block is useful in selected patients with a wrist fracture.

Femoral nerve block in the initial management of femoral shaft fractures.

The aim of this study was to demonstrate that the under-used technique of femoral nerve block (F.N.B.) (Berry, 1977) has excellent analgesic action for femoral shaft fractures when performed by junior staff. It had no recorded side effects and was used in all age groups for fractures at all levels along the femoral shaft. Twenty-seven consecutive patients were studied as they presented in an accident room, all received a femoral nerve block (10 ml 1% Lignocaine with 1:200,000 adrenaline) from unsupervised junior accident and emergency staff instructed in the technique. Each case was subsequently followed up, and both the delay before the onset of analgesia and total duration of analgesia, together with its efficacy, were assessed. A further F.N.B. using a different agent (10 ml 0.5% bupivacaine) was performed and the same parameters were assessed. Both agents gave effective analgesia of varying duration at all levels of fracture site.

Posterior dislocation of shoulder and bilateral hip fractures caused by epileptic seizure.

A case in which a patient with normal bone texture suffered a posterior shoulder dislocation combined with bilateral sub-capital femoral neck fractures during an ictal episode and in which the diagnosis of bilateral hip fractures was delayed is described.

Measuring anti-convulsant levels in the accident and emergency department.

A prospective study involving 57 epileptic adults who presented to the Derbyshire Royal Infirmary Accident and Emergency Department with fits has shown that 57% were in the sub therapeutic ranges.