NHS Tayside ED Guidance- 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
Paediatric ketamine sedation checklist and protocol
- Obtain IV access.
- Monitors and SpO2 probe attached and timer started. N.b. O2 mask is not required if saturations are normal.
- 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.
- Ensure resuscitation drugs are available and dose of suxamethonium calculated and noted.
- Ensure all procedural equipment and staffing are ready.
- Deliver bolus of 1mg/kg of ketamine intravenously. This should provide 10 minutes of sedation and analgesia.
- If inadequate then deliver further 0.5mg/kg IV. There is no need for supplemental benzodiazepines or atropine.
- Continue with procedure.
- 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.
- When child is responding appropriately to voice there is no requirement for ongoing monitoring. However, be prepared for vomiting – the most common side effect.
- 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.