Although setting fractures and joint dislocations are among the most painful pediatric emergencies, some emergency departments around the country still opt for a papoose board -- on which the injured child is restrained by bedsheets or Velcro -- instead of pain killers.
Robert M. Kennedy, M.D., an associate professor of pediatrics at Washington University School of Medicine in St. Louis, believes emergency physicians don't use analgesics because they're afraid of the adverse effects and might not know the proper dosage. Partly to combat this problem, he and colleagues compared two regimens for sedating children. They found that one of them -- involving the drugs ketamine and midazolam -- was safer and slowed breathing less than the other. Both regimens, however, did prevent patients from remembering the painful procedures.
Kennedy recently published this study in the journal Pediatrics. He hopes the finding will encourage more emergency physicians to carefully sedate their young patients during painful procedures. "This study showed that we have established safe means and relatively safe doses that other physicians can use so that kids don't have to be held down and restrained during these necessary procedures," he said.
This work was supported in part by a grant from the Health Resources and Services Administration, Maternal and Child Health Bureau, and Emergency Medical Services, and a grant from the National Institute of Child and Human Development.
Signs Of Distress
The study involved 260 patients between ages 5 and 15 whose fractures and joint
dislocations were set in St. Louis Children's Hospital Emergency Department at
the Washington University Medical Center. The children were randomized into two
groups: one received ketamine/midazolam for sedation and pain relief, and the
other received fentanyl/midazolam, another pain relief combination. Before and
during sedation, the researchers measured patients' levels of consciousness,
lung and heart functions and blood levels of oxygen. Signs of distress such as
crying and screaming were rated by trained observers, as well as by the
patients' parents.
Patients who received ketamine/midazolam had much lower distress scores and parental ratings of pain and anxiety than the children who received fentanyl/midazolam. Orthopedists also favored this drug combination over fentanyl/midazolam. Most of the patients in both groups experienced complete amnesia during their procedure.
Patients in the ketamine/midazolam group continued to breathe normally and didn't require as much supplemental oxygen. Only six percent of the patients who received ketamine/midazolam had drops in blood oxygen levels vs. 25 percent of the children in the fentanyl/midazolam group.
In addition to determining which drug combination is safer and more effective, Kennedy said this study provides useful information to parents. "Parents need to know there are means of sedation and analgesia for children undergoing painful procedures. If the emergency department where their child is being treated can't provide them, I think they need to consider whether the child should be transferred to an emergency department that can," he added.
Many health-care providers believe not managing pain in children who undergo these procedures can greatly scar patients psychologically. "We believe the psychological impact is tremendous," Kennedy said.
The long-term goal of this research is to identify the most effective and safest methods for managing pain and anxiety during a variety of painful emergency procedures. "I would like to see effective pain and anxiety relief during painful pediatric procedures become very routine," Kennedy said. "And I hope this study will do away with papoose boards and other forms of restraints forever."
Note: For more information, refer to Kennedy RM, Porter FL, Miller JP, Jaffe DM, "Comparison for Fentanyl/Midazolam With Ketamine/Midazolam for Pediatric Orthopedic Emergencies," Pediatrics, 102, 956-63, October 1998.
Journal
PEDIATRICS