Protocol for administration of ketamine to children in the A&E department
| (Adapted from Ketamine protocol—Loma Linda University ED by kind permission of Steve M Green, MD). |
| Patients: |
| Children requiring short, painful interventions. For example, suturing complex lacerations, incision and drainage of abscesses, minor orthopaedic manipulations, repair of finger tip injuries, etc. |
| Contraindications: |
| • Active lung disease or infection including URTI. (Asthma not contraindicated.) |
| • Cardiovascular disease, for example, congenital, cardiomyopathy, hypertension. |
| • Head injury if associated with history of loss of consciousness, vomiting, altered mental state, or any sign of raised intracerebral pressure. |
| • Central nervous system disease, for example, hydrocephalus, intracranial mass, epilepsy. |
| • Others: porphyria, thyroid disease, glaucoma, psychosis. |
| Preparation: |
| • Ensure child is starved for minimum of three hours. |
| • Record weight in kilograms. |
| • Obtain written consent from guardian after explaining potential risks/side effects of procedure. |
| • Apply EMLA cream 60 minutes before procedure over the area for injection. |
| • Encourage parent to stay with child during procedure and recovery. |
| Requirements: |
| • Presence of two doctors, at least one trained in paediatric resuscitation. |
| • Presence of qualified nurse ideally with paediatric experience to monitor the child until fully recovered. |
| • Record baseline vital signs before drug administration. |
| • Equipment needed: oxygen, suction, vital sign monitors including pulse oxymeter and a full paediatric resuscitation trolley. (Intravenous access not essential.) |
| • A designated area where noise and disturbance are minimal. |
| Dose: |
| Ketamine 5 mg/kg as initial dose 2 mg/kg if repeat dose required at 10 minute intervals. Atropine (100–200 μg/kg) may be added to minimise ketamine associated hypersecretion. |
| Procedure: |
| • Ketamine (and atropine if required) are administered intramuscularly into the pre-anaesthetised skin over buttock or thigh. Child to be held in parent's arms if possible. |
| • Once sedated the child is placed on their side on a tilting trolley with continuous pulse and oxygen saturation monitoring. |
| • Optimise airway position, occasional gentle suction of oropharynx may be required to clear secretions. |
| • Monitor continuously until fully recovered. |
| • Recovery area should be quiet if possible, with minimal tactile stimulation. Mean recovery time is 60–140 minutes. |
| Side effects: |
| Observe for: airway compromise—that is, laryngospasm, apnoea, hypersalivation. |
| Also, vomiting, agitation, hallucinations, nightmares, ataxia. |
| Discharge: |
| • When child has returned to pre-treatment level of awareness, recognition, speech, and purposeful activity. |
| • Instruct parents to give nothing by mouth until fully orientated and closely observe ambulation for next 24 hours. |