Procedural Sedation for Orthopedic Fracture Reductions in the Pediatric Emergency Department

Abstract

To provide an updated literature review on pediatric procedural sedation in the emergency department. Discuss patient evaluation, monitoring, indications, and contraindications of common pharmacologic agents used for procedural sedation during orthopedic fracture reductions in the pediatric emergency department. Literature search from 1995 to 2015 was conducted using MEDLINE (PubMed), CINAHL, Cochraine and EMBASE databases. Terms included; procedural sedation, fracture reduction, orthopedic reduction, fasting, monitoring, capnometry, Bispectral index and pediatric procedural sedation. We identified a total of 1268 publications covering the literature search criteria listed above. Twenty-two studies evaluated procedural sedation for reduction of closed skeletal injuries in the pediatric emergency department (eight retrospective case series, five prospective case series and nine randomized controlled clinical trials). The published literature utilized different pain assessment scales, pharmacologic agents, and satisfaction evaluation methodology. Ketamine alone or in combination with midazolam was the most common sedation agent used in the published literature. The use of procedural sedation for performing painful procedures in the pediatric emergency department is common. Ketamine and nitrous oxide are the most commonly used pharmacologic agents. Both agents have an excellent safety profile when published sedation guidelines are followed. Patient monitoring is the single most critical element for providing safe sedation in the emergency department. There are several adjuncts for providing safe and effective sedation in the emergency department including capnography, Ramsay sedation scale, Bispectral index, and aldrete score.