Table 4

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).
Children requiring short, painful interventions. For example, suturing complex lacerations, incision and drainage of abscesses, minor orthopaedic manipulations, repair of finger tip injuries, etc.
• 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.
• 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.
• 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.
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.
• 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.
• 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.