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Midazolam and emergence phenomena in children undergoing ketamine sedation
  1. Simon Carley,
  2. Bruce Martin
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
  1. Correspondence to: Kevin Mackway-Jones, Consultant (kevin.mackway-jones{at}

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Report by Simon Carley,Specialist Registrar Search checked by Bruce Martin, Specialist Registrar

Clinical scenario

A 4 year old boy presents to the emergency department with a 4 cm laceration to the thigh. This requires cleaning and layered suture closure. You decide to sedate him using ketamine intramuscularly. You are successful and close the wound. However, while he is recovering he seems to be experiencing unpleasant hallucinations. You wonder whether a small dose of midazolam given with the ketamine would have prevented this.

Three part question

[In children undergoing ketamine sedation in the emergency department] is [benzodiazepines plus ketamine better than ketamine alone] at [reducing emergence phenomena and minimising complications and time of sedatrion]?

Search strategy

Medline 1966–02/01 using the OVID interface. [(exp ketamine OR AND (exp benzodiazepines OR OR exp midazolam OR OR exp diazepam OR OR OR exp lorazepam OR OR hyponotics and OR AND ( OR] LIMIT human, english AND abstracts.

Search outcome

Altogether 71 papers found of which only one was relevant. An additional paper has recently been published and was not indexed on Medline at the time of searching. These two papers are shown in table 5.

Table 5


These two well designed studies investigate the question directly. There seems to be no advantage in the addition of midazolam for IV ketamine sedation. Its use in IM ketamine sedation may be different as the pharmacokinetics of both drugs may be different via the IM route.

Clinical bottom line

Midazolam is not needed as an adjunct to ketamine sedation in children.

Report by Simon Carley,Specialist Registrar Search checked by Bruce Martin, Specialist Registrar