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Report by Andrew Munro, Specialist in Emergency Medicine FACEM
Checked by Ian Machonochie, Consultant in Paediatric Emergency Medicine
Coffs Harbour Base Hospital, NSW, Australia
A short cut review was carried out to establish whether ketamine or midazolam is superior at providing safe and effective conscious sedation in children in the emergency department. A total of 203 papers were found using the reported searches, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are summarised in table 11.. It is concluded that midazolam and ketamine have similar efficacy and safety profiles but that ketamine is preferred by parents and physicians.
In [children needing painful procedures in the emergency department] is [midazolam or ketamine] [safer and more effective at achieving conscious sedation]?
A mother brings her 5‐year‐old son to the emergency department with a deep scalp laceration, having fallen onto the corner of a coffee table. The wound requires sutures. For various reasons the option for procedural sedation in this department is limited to midazolam. Due to your past experience, you are more comfortable using ketamine. Although there is a large amount of data in the emergency literature to show efficacy and safety for both agents, you are not aware of direct comparisons to back your preference for ketamine in children in the emergency department setting.
Medline 1960–April 2007 using the OVID interface: (exp ketamine/or ketamine.mp.) AND (exp midazolam/or midazolam.mp.) AND (exp child/ or “children”.mp. or exp pediatrics/ or “pediatric”. mp.). LIMIT to human AND English language.
The Cochrane Library Issue 2, 2007: MeSH descriptor Ketamine explode all trees AND MeSH descriptor Midazolam explode all trees AND (emergency department):ti,ab,kw 7 papers none relevant
Of the 203 papers found in Medline, 199 were found to be irrelevant or of insufficient quality for inclusion. Of seven papers found in Cochrane none were relevant. The remaining four papers are summarised in table 11.
The available comparative studies involved multiple agents and combinations, routes of administration and doses. No head to head trials of intravenous ketamine versus intravenous midazolam for procedural sedation in children in the emergency setting could be found. Secondary findings show that satisfaction of parents and physicians was greater with ketamine and that physicians felt it was safer.
Ketamine and midazolam have similar safety profiles in the emergency setting for children. Ketamine causes more vomiting but appears to be the preferred agent for most parents and many emergency department physicians.