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Intramuscular ketamine in A&E

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Ketamine was first developed over 40 yeas ago. It was used in the field by the US army in Vietnam and has been used extensively throughout the world (but not very much in Britain) since then. It produces anaesthesia, analgesia, and amnesia with preservation of respiratory protective reflexes. Reports of its use by non-anaesthetists for procedural sedation in children first appeared in the early 1990s. Now staff at two English accident and emergency departments have independently described their experience with intramuscular ketamine for children needing minor surgical procedures.

In

) 89 children aged 1–10 years received intramuscular ketamine 4 mg/kg with atropine 0.02 mg/kg over the course of 1 year. In Lancaster (

) there were 500 patients aged up to 12 years (mean 3.6 years) over a period of 5 years and 9 months and the dose of ketamine was 2.5 mg/kg (190 children) or 2 mg/kg (310) with atropine 0.01 mg/kg. Both departments had protocols for the use of ketamine and provided parents with written and verbal information. Both used clinical and pulse oximetry monitoring and medical and nursing staff, including somebody with advanced paediatric resuscitation skills, were present throughout. Both departments encouraged parental presence. Four children (Welwyn Garden City) and 26 (Lancaster) received a second dose of ketamine of about half the first dose (about 5% in each centre). Adequate sedation was usually achieved within 10 minutes and few children needed to be restrained. Oxygen desaturation (<94%) did not occur in the WGC series and occurred in eight children in Lancaster. It was transient in all cases, responding to oxygen supplementation in one child with laryngospasm. The children were usually ready for discharge within 2 hours although recovery was slower in some. About 10% of patients vomited in the department and a further 10% after going home; it was more likely in children given a second dose. Some unsteadiness after returning home was fairly common and some agitation during recovery and later occurred in around 15–20%. Ninety-five per cent or more of parents were satisfied with the use of ketamine.

Both of these departments now use ketamine routinely but both emphasise the importance of staff training, adequate staffing levels, and careful monitoring.

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