Ketamine-Propofol Combination Sedation for Fracture Reduction in the Pediatric Emergency Department

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Abstract
Objectives To evaluate the time of onset and recovery from and the efficacy and safety of intravenous ketamine-propofol sedation for reduction of forearm fractures in the pediatric emergency department setting. Study Design Prospective, observational pilot study. Methods Children presenting to an urban pediatric emergency department requiring sedation for closed reduction of forearm fractures received ketamine 0.5 mg/kg and propofol 1 mg/kg. We measured time intervals from drug administration to reduction, recovery, and attainment of discharge criteria, and obtained ratings of depth of sedation, pain, and ease of reduction. A follow-up survey elicited patient recall, parental satisfaction, and delayed complications. Complications were recorded during the procedure and by chart review. Results Reduction was successful in 19 of 20 patients with one requiring open reduction. Median time intervals measured from initiation of ketamine injection were 5 minutes to reduction completion, 10 minutes to first purposeful response, and 38 minutes to suitability for discharge. Three patients recalled reduction or casting, but in no case was reduction reported to be the most painful aspect of visit. Emergency physicians and orthopedic residents rated sedation and ease of reduction favorably. Complications included mild hypoxia, vomiting, and transient ataxia. No apnea, hemodynamic compromise, dysphoria, or injection pain occurred. Conclusions In this pilot study, the combination of ketamine and propofol provided effective sedation with rapid recovery and no clinically significant complications for children requiring closed reduction of forearm fractures.