• Select appropriate paediatric resuscitation sheet for age or weight
• Ensure ability to perform bag mask ventilation
• Knowledge of contraindications to sedation with ketamine
• Appropriate staffing as per current sedation practice
• Sedation form available
• Ambubag and appropriate sized face mask assembled and connected to oxygen supply
• Suction apparatus checked and functioning
• Appropriate sized laryngoscope blade and functioning laryngoscope checked and available
• Appropriate sized ETT available
• Head of bed away from wall to permit access to airway
• Ensure familiarity with laryngospasm treatment algorithm 

1. Obtain IV access.
2. Monitors and SpO2 probe attached and timer started. N.b. O2 mask is not required if saturations are normal.
3. Ketamine drawn up and and checked with nurse assisting. Standardized method of 100mg drawn up and diluted with 0.9% saline in a 10ml syringe, giving a concentration of 10mg/ml.
4. Ensure resuscitation drugs are available and dose of suxamethonium calculated and noted.
5. Ensure all procedural equipment and staffing are ready.
6. Deliver bolus of 1mg/kg of ketamine intravenously. This should provide 10 minutes of sedation and analgesia.
7. If inadequate then deliver further 0.5mg/kg IV. There is no need for supplemental benzodiazepines or atropine.
8. Continue with procedure.

1. Nurse the child in as quiet an area as possible with lights dimmed. It will take approximately 60 minutes for the sedation to wear off.
2. When child is responding appropriately to voice there is no requirement for ongoing monitoring. However, be prepared for vomiting – the most common side effect.

Paediatric IV ketamine laryngospasm protocol

• Age less than 2 years due to an increased risk of laryngospasm
• A high risk of laryngospasm (active respiratory infection, active asthma)
• Unstable or abnormal airway. Tracheal surgery or stenosis
• Active upper or lower respiratory tract infection
• Proposed procedure within the mouth or pharynx
• Patients with severe psychological problems such as cognitive or motor delay or severe behavioural problems
• Significant cardiac disease (angina, heart failure, malignant hypertension)
• Recent significant head injury or reduced level of consciousness
• Intracranial hypertension with CSF obstruction.
• Intra-ocular pathology (glaucoma, penetrating injury)
• Previous psychotic illness
• Uncontrolled epilepsy
• Hyperthyroidism or thyroid medication
• Porphyria
• Prior adverse reaction to ketamine

The problem is complicated by more serious injury which would be best managed with a general anaesthetic.

Tayside paediatric procedural sedation form

1. Adapted from The College of Emergency Medicine Guideline for Ketamine Sedation of Children in Emergency Departments 2010.