Sedation for peds lacerations

[GeneralVeers]

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Does anyone else dread doing laceration repairs on 1-4 year old kids? A few weeks ago a peds attending let me give some po Versed to a 3 year old with a lip lac. That was one of the easiest repairs I've ever done. Subsequent attendings have not allowed me to use any kind of sedation saying that it is too "risky". Personally I'd give sedation for any kid when they can't cooperate. What do the rest of you use, if anything at all, and is it really too "risky"?

 

[FoughtFyr]

Does anyone else dread doing laceration repairs on 1-4 year old kids? A few weeks ago a peds attending let me give some po Versed to a 3 year old with a lip lac. That was one of the easiest repairs I've ever done. Subsequent attendings have not allowed me to use any kind of sedation saying that it is too "risky". Personally I'd give sedation for any kid when they can't cooperate. What do the rest of you use, if anything at all, and is it really too "risky"?

We sedate all of our peds laceration repairs unless the child can be easily distracted. I've used everything from intranasal versed to propofol.

- H

 

[GeneralVeers]

We sedate all of our peds laceration repairs unless the child can be easily distracted. I've used everything from intranasal versed to propofol.

- H

I've heard about the intranasal Versed, but never worked at a hospital that used it. How do you like it?

 

[FoughtFyr]

I've heard about the intranasal Versed, but never worked at a hospital that used it. How do you like it?

It's o.k. My personal preference is propofol. Quick on, quick off and if done correctly (slow pushes over minutes with capnography in place) the risk is minimal. I've had a few failures with the intranasal versed where the patient just became disinhibited and I've had to "up the ante" to full on sedation. I just prefer to start there. If you are looking for some literature to "back up" the use of sedation in peds (especially propofol) look to the recent literature out of Utah's peds EM fellowship. Jana Anderson (now at Mayo) has published on it as have many of the other folks there...

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/e...med.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/e...med.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

In short, you ain't stitching my kid without sedation!

- H

 

[edinOH]

I like an IM shot of Ketamine for the lac repairs. Able to avoid the IV stick and it's safe. I typically get the kid ready, give the injection, dim the lights and wait a few minutes. For more complicated repairs or reductions I like propofol. Propofol is a helluva drug.

I think it is barbaric not to use sedation if the alternative is a papoos or just plain muscle. It's more of a hassle at times but sedation saves the kid alot of emotional trauma. Not to mention the trauma it saves the parents.

 

[Cheecheroo]

Has anyone used or heard of ketafol being used with the kiddies? My limited experience (observer) involved adults only. Seems like a great drug combo though.

 

[FoughtFyr]

Has anyone used or heard of ketafol being used with the kiddies? My limited experience (observer) involved adults only. Seems like a great drug combo though.

Heard of it, but really not as needed in kids. The propofol is added to help with the dissociation adults experience with ketamine. Peds don't seem to mind the ketamine as much so the propofol isn't needed to blunt it. I use a bunch of straight propofol in both kids and adults. We do a ton of concious sedation here (I've got >100 cases in my log over the past three years - both adult and peds). I've used just about everything a fair number of times. IMNSHO propofol is the best all around with ketamine a close second in kids and fentanyl / versed as my adult "second line" (when hypotension prevents the propofol - etomidate if allergy prevents the propofol).

- H

 

[macdaddy23]

I like the ketamine myself.

Haven't used the po versed.

General what dose do you use and how long after were they able to discharge?
Thanks

 

[roja]

I love nitrox

 

[geordon]

I like an IM shot of Ketamine for the lac repairs. <snip>

I think it is barbaric not to use sedation if the alternative is a papoos or just plain muscle. It's more of a hassle at times but sedation saves the kid alot of emotional trauma. Not to mention the trauma it saves the parents.

I was thinking that Special K would be a good way to go. Speaking from the perspective of both a child-patient and a parent, I am SO with you on preferring sedation to brute-force restraint. When I was about 5, I lac'd my head and was basically tied down so they could put stitches in. I'm 34, and I still remember the episode vividly. Ugh.

About 2 years ago, my (now) 7 y.o. daughter got her lip split open by our parrot, about 1/4 inch above the vermilion border, and 1/8 under. Took her to the ER, since it was pretty deep, and it took 4 full-size+ adults to hold her down: One on her chest and one arm, one on each leg, and the last on her other arm. Only 2 stitches, and the scar is barely visible, unless you know exactly where to look.

We could barely hold her down. I'm just glad that she doesn't hate me for laying on top of her. I'm sure that there will be plenty of things that she'll hate me for as she hits the teen years.

So, yeah, PLEASE sedate kids (esp. the younger ones) to do lac repairs. It's better, all around.

 

[bartleby]

For < 8 with lacerations or painful fracture reductions, I prefer IV ketamine. If you need extra time, you can give an additional with quicker effect than IM, plus, it doesn't hang around quite as long when given IV. You also have access for antiemetics, etc when they're recovering. Propofol for the older kids for painful proccedures are great because there's no risk of emergence reactions, and the recovery is much faster than with special K.

 

[docB]

I love nitrox

Nitrox is good stuff. Really safe too. It fell out of favor when that requirement came down about having to have a scavenger system and the apparatus became prohibitively expensive. I frequently wish I had it for lacs and such.

 

[Dr.Evil1]

Now facial/complex lacs are a different story but I LOVE dermabond and staples. You usually don't have to even hold them down for dermabond and you can usually get 2 staples into a kid before they really know what hit them.

 

[spyderdoc]

I am pretty much a ketamine/atropine IM kind of a guy if I need to sedate...

Unfortunately, our anesthesiology dept won't let us use etomidate or propofol for sedation (on adults either!). We can however use etomidate for RSI. Although I routinely show them articles supporting the use of these most excellent agents, they say "it is against our philosphy" to let us use the etomidate and propofol for sedation (real evidence based reason, huh?)....But, we just got our department status, so now we are pretty much free to write our own policies, so this is one of the first on our agenda, and the rest of the med staff supports us......

 

[PAJenn]

peds lacs are the worst! i usually try to look real busy or find my way to lunch when i see one of them coming lol!

po versed is great...

but sometimes a little benadryl does the trick!

 

[Hawkeye Kid]

po versed is great...

my girlfriend is a peds dentist and they use po versed all the time (they also use demerol and chloral hydrate...) but the downsides are pretty significant. you have to wait for effect and, since the absorption isn't all that reliable, re-dosing is a problem.

personally, i'll gauge the kid to see if i think we can get away without sedation--involving parents if they're helpful--but usually will go with IM ketamine +/- atropine. you can always start an IV after the ketamine kicks in if you think you'll need it.

 

[geordon]

Unfortunately, our anesthesiology dept won't let us use etomidate or propofol for sedation (on adults either!). We can however use etomidate for RSI. Although I routinely show them articles supporting the use of these most excellent agents, they say "it is against our philosphy" to let us use the etomidate and propofol for sedation (real evidence based reason, huh?)

WTF kind of "philosophy" is that? Can you try to find out what the *real* reason is? I mean, if it's their "philosophy", then they should be able to explain why they feel that way.

Crazy.

 

[ERMudPhud]

WTF kind of "philosophy" is that? Can you try to find out what the *real* reason is? I mean, if it's their "philosophy", then they should be able to explain why they feel that way.

Crazy.

I'm betting its mostly about $$$. Spyder's at a high reimbursement site and I'm betting the gas passers would be more than happy to come and proved conscious sedation services 24/7 since they are probably in house anyway and can bill a bunch for it. That is part of why we have had to fight so hard to be able to use those drugs in our hospitals. I used to suggest calling them in at 3AM for every sedation until I realized they would be more than happy to do it.

 

[spyderdoc]

I'm betting its mostly about $$$. Spyder's at a high reimbursement site and I'm betting the gas passers would be more than happy to come and proved conscious sedation services 24/7 since they are probably in house anyway and can bill a bunch for it. That is part of why we have had to fight so hard to be able to use those drugs in our hospitals. I used to suggest calling them in at 3AM for every sedation until I realized they would be more than happy to do it.

Yep, I believe this is mostly the reason. Pretty sad, huh? This plus the fact that the most verbal ones are the old timers who believe that they are the only ones capable of handling these meds and a possible loss of airway, and us EM buffoons are not...Unfortunately, they forget that the Fentanyl/Versed combo also results in prettty deep sedation, lasts longer, and seems to result in more respiratory depression than these newer, safer meds....Oh well, it's a tough battle, but we are persistent little buggers and will eventually prevail...

It worked with the radiologists, and we finally got our Sonosite last week! Boy did I work hard to get that machine....I think with the radiologists, their main interest is to NOT pay the night hawk radiologists, so if we can do an U/S in the middle of the night, and not utilize the night hawks, the radiologists are more than happy about this....Plus, we are not billing for the ultrasound stuff that they can provide, like GB, AAA, pelvic, etc. We can bill for stuff they don't provide, like U/S guided procedures...I put in an IJ dialysis catheter the other night with the U/S...Boy was that sweet knowing that I wasn't putting that garden hose into the carotid!

Well, I guess we are winning the turf battles one by one, so I guess the sedation issue will take more time, but I am sure we will win the battle....We just became our own department, so we now have some more "power" with the hospital admin....I'll keep you posted....

 

[Quimby2]

GV, that age range and for that particular type of procedure is crying out for ketamine. Use it IV if you expect repeated dosing and your RN's are great at IV's; otherewise, IM is wonderful as well. My rec is to use the higher end of the spectrum for dosing (i.e. 4-5mg/kg IM and 1.5-2mg/kg IV). The reason for the higher dosing is that the response to pain leaves just after the dose at which you appear to be dissociated. This drug is ultra safe and much more predictable than Versed (which has varied dose-responses among different patients and can often disinhibit instead of sedate....just like the last time you danced on the bar after a couple drinks). You can repeat the Ketamine dosing a few times during the procedure if you need to since once it is at a therapeutic dose, it does not further supress any protective airway reflexes or vitals with additional dosing (it will only prolong duration of action). No matter what dose you use, the patient will retain protective reflexes --that is he is protected from aspiration. One word of caution with ketamine, and all sedatives, even if your airway reflexes are intact, you still might nod your head forward and suffocate SO MAKE SURE HEAD IS IN NORMAL POSITION AND PULSE OX IS ON.

Ketamine. Use it. Preach it. Live it!