Painter1

Junior Member
10+ Year Member
7+ Year Member
Mar 16, 2006
214
0
0
Status
2yo s/p ground level fall with head injury. period of AMS while in ed. however after iv placment now agitated.

sedation of choice for head ct?
 

emedpa

GlobalDoc
10+ Year Member
15+ Year Member
Aug 25, 2001
6,014
301
381
Taking an Away team....
Status
Post Doc
I just took APLS and the peds intensivist presenting there liked po versed for this indication. no issues with iv access causing more agitation, etc
my understanding was also that ketamine is a no-no in the setting of head injury as it increases ICP.(at least it was presented that this was the current thought when I took the difficult airway course recently).
 

emedpa

GlobalDoc
10+ Year Member
15+ Year Member
Aug 25, 2001
6,014
301
381
Taking an Away team....
Status
Post Doc
IM ketamine.

I like to start fights with nursing that I can't win.

if you draw it up and give it yourself( as I have) you win that fight.
 

southerndoc

life is good
Moderator Emeritus
Lifetime Donor
15+ Year Member
Jun 6, 2002
11,908
868
381
Atlanta
Status
Attending Physician
ketamine is contraindicated in head injury. at least this is what i thought.
Which increases ICP more, the ketamine or the kid fighting on the table and being restrained?

This is like the lidocaine pre-treatment for RSI in head injured patients. Laryngoscopy and ketamine might increase ICP, but there isn't any evidence to suggest it does any harm.
 

DogFaceMedic

Member
10+ Year Member
5+ Year Member
Jul 18, 2006
552
2
0
Status
Resident [Any Field]
J Neurosurg Pediatr. 2009 Jul;4(1):40-6. Effectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension.

Also, apparently the Israeli Army uses Ketamine for brain injuries, and the original research about ketamine and ICP was anesthesia research of pts w/ tumors and a small n. But, I haven't used it yet.
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
Disclaimer: I don't necessarily know what I'm talking about, so take this post with a grain of salt.

IMHO, Ketamine's the best choice for peds sedation even with suspected head injury unless there's already elevated ICP due to hemorrhage, which you should be able to identify via ophtho exam (papilledema, swollen optic nerve). If not, Ketamine's rapid onset should make it a go-to in this instance. Just my 2¢. :)
 

Painter1

Junior Member
10+ Year Member
7+ Year Member
Mar 16, 2006
214
0
0
Status
Disclaimer: I don't necessarily know what I'm talking about, so take this post with a grain of salt.

IMHO, Ketamine's the best choice for peds sedation even with suspected head injury unless there's already elevated ICP due to hemorrhage, which you should be able to identify via ophtho exam (papilledema, swollen optic nerve). If not, Ketamine's rapid onset should make it a go-to in this instance. Just my 2¢. :)

the thing with using ketamine in head trauma is that it isn't standard of care. standard of care usually lags these new studies finding no basis in what was thought to be common sense.

worse case scenario u give ketamine for ct sedation in a kid that herniates or develops neuro deficits. the ketamine likely had nothing to do with the outcome but there won't be a shortage of lawyers ready to take you for all of what your worth, including the shirt on your back.

i emailed my old peds EM attending.

pentobarb is his recommendation. after some reading, pentobarb is superior to versed in terms of success rate for adequate sedation in ct imaging in peds.

the problem at my place is that i can't use pentobarb.

anyone use etomidate?
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
the thing with using ketamine in head trauma is that it isn't standard of care. standard of care usually lags these new studies finding no basis in what was thought to be common sense.

worse case scenario u give ketamine for ct sedation in a kid that herniates or develops neuro deficits. the ketamine likely had nothing to do with the outcome but there won't be a shortage of lawyers ready to take you for all of what your worth, including the shirt on your back.

the problem at my place is that i can't use pentobarb.

anyone use etomidate?
If the kid herniates, you've probably missed some pretty major warning signs, indicative of an insufficiently thorough physical exam (optho exam, head trauma→raised ICP via hematoma or contusions→Cushing's triad?). It's unlikely that the Ketamine would've caused it. Critically elevated ICP is a physical diagnosis; if the signs are there, you treat it, but it's very unlikely (IMHO, which once again, may easily be wrong) that Ketamine would push a ped with ≤10-20mmHg to ≥35mmHg at a 1mg/kg slow push.

I think etomidate would be overkill for rads sedation; perhaps methohexital if you can get the pt in quickly enough? Or if you're worried about ICP, thiopental (although have to watch for that long-acting effect)?
 

EM2BE

Elf
10+ Year Member
7+ Year Member
Apr 6, 2006
10,622
5
141
Somewhere over the rainbow
Status
Resident [Any Field]
Disclaimer: I don't necessarily know what I'm talking about, so take this post with a grain of salt.

IMHO, Ketamine's the best choice for peds sedation even with suspected head injury unless there's already elevated ICP due to hemorrhage, which you should be able to identify via ophtho exam (papilledema, swollen optic nerve). If not, Ketamine's rapid onset should make it a go-to in this instance. Just my 2¢. :)
The only question I have is if the kid is awake (assuming they are if you are trying to sedate them) and young, how do you keep them still enough to do a thorough ophtho exam? Assuming you can hold them down and still, that would increase the ICP if they fight, so that kind of defeats the purpose.
 

Rendar5

15+ Year Member
Nov 12, 2003
6,990
615
381
Florida
Status
Attending Physician
If the kid herniates, you've probably missed some pretty major warning signs, indicative of an insufficiently thorough physical exam (optho exam, head trauma→raised ICP via hematoma or contusions→Cushing's triad?). It's unlikely that the Ketamine would've caused it. Critically elevated ICP is a physical diagnosis; if the signs are there, you treat it, but it's very unlikely (IMHO, which once again, may easily be wrong) that Ketamine would push a ped with ≤10-20mmHg to ≥35mmHg at a 1mg/kg slow push.

I think etomidate would be overkill for rads sedation; perhaps methohexital if you can get the pt in quickly enough? Or if you're worried about ICP, thiopental (although have to watch for that long-acting effect)?
While I agree that ketamine would not push the kid to increased ICP, increased ICP can still happen down the line, and if you used ketamine, people will look for someone to blame. It's easier to blame the doctor, even if the ketamine wasnyoure' wrong, than to blame the accident. Gotta wait until most docs are ok with ketamine in head trauma.
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
The only question I have is if the kid is awake (assuming they are if you are trying to sedate them) and young, how do you keep them still enough to do a thorough ophtho exam? Assuming you can hold them down and still, that would increase the ICP if they fight, so that kind of defeats the purpose.
OP stated that pt didn't get agitated until after IV placement. Couldn't anyone have gotten eye impressions during triage or in EMS? What about bp, etc? What happened before the IV was placed? Was IV access ordered prior to even seeing the pt? Those were just some of the things I was considering; if the pt was calm enough to get an IV placed, wouldn't he be calm enough to have his eyes looked at?
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
While I agree that ketamine would not push the kid to increased ICP, increased ICP can still happen down the line, and if you used ketamine, people will look for someone to blame. It's easier to blame the doctor, even if the ketamine wasnyoure' wrong, than to blame the accident. Gotta wait until most docs are ok with ketamine in head trauma.
So is acute ICP spiking always your concern for any head injury +AMS (on a 2yo) -LoC (I assume since OP didn't mention that) that is otherwise asymptomatic for any further evidence of ICP? If mass effect-induced ICP is a concern for you, why wasn't there a NSGY consult (in which case, no sedation until pt is seen by NSGY)? If there's M&M due to ICP and you didn't follow ICP protocols from the getgo, you can still get slammed for that as well. The head CT really shouldn't be precluding the physical exam. (Once again, disclaimer, I may easily be wrong and am not an expert, so don't make any clinical decisions based on this post)
 

EM2BE

Elf
10+ Year Member
7+ Year Member
Apr 6, 2006
10,622
5
141
Somewhere over the rainbow
Status
Resident [Any Field]
OP stated that pt didn't get agitated until after IV placement. Couldn't anyone have gotten eye impressions during triage or in EMS? What about bp, etc? What happened before the IV was placed? Was IV access ordered prior to even seeing the pt? Those were just some of the things I was considering; if the pt was calm enough to get an IV placed, wouldn't he be calm enough to have his eyes looked at?
I was asking in general, not just pertaining to this case.
 

emedpa

GlobalDoc
10+ Year Member
15+ Year Member
Aug 25, 2001
6,014
301
381
Taking an Away team....
Status
Post Doc
in the stable kid who just needs a cya head ct many of us at my institution skip the IV and just use oral versed.ditto for minor procedures. LET+ oral versed can get you out of a lot of procedural sedation paperwork and hassles.
 

WilcoWorld

Senior Member
10+ Year Member
Nov 2, 2004
2,998
1,720
281
Status
I like to avoids IV's in these patients whenever possible so I usually go with PO versed or PR brevital. There is some promising research (not yet published) that soothing music might do the trick in little kiddos, and I've had plenty of success with nothing more than a sugar-soaked pacifier.

I've been hearing the buzz that ketamine is safe and might actually become the preferred agent in head injury, but I haven't read anything on it, so I haven't changed my practice...yet.

Lastly, I share EM2BE's skepticism about performing a good retinal exam on a kid who needs sedation for a CT. I have a hard enough time even seeing their pupils.

All of the above assumes that I have a low (but not no) index of suspicion for ICH. If I really think the kid has a bleed they'll get an IV before CT, and I use something short acting.
 

Stitch

Jedi Ninja Wizard
Moderator
15+ Year Member
Dec 12, 2002
5,594
104
481
Texas
Status
Attending Physician
I would posit that you might not need sedation at all for a dry head CT. We frequently just hold them down with velcro and duct tape (okay not really), and get a satisfactory scan. Allow a parent to put on some lead and go into the room with him.

That said if the kid is really agitated, a little versed can really go a long way without the need for much else. There's increasing hype about ketamine, and it's looking like it's probably safe. A lot of the neurosurgeons say that in people with bolts, their ICP doesn't change after administration. I haven't started using it yet, but I've talked with people who have.

My problem with pentobarb is that it's a bit long acting for what you're doing.

Finally if you haven't read the PECARN study on head CTs in children you should. We have it up on all our computers to reference the flow chart, and it's definitely cut down on the number of scans we do.
 

southerndoc

life is good
Moderator Emeritus
Lifetime Donor
15+ Year Member
Jun 6, 2002
11,908
868
381
Atlanta
Status
Attending Physician

Dr.McNinja

Nobel War Prize Winner
Moderator
10+ Year Member
Aug 2, 2006
9,805
6,191
381
Texas
Status
Attending Physician
Couldn't anyone have gotten eye impressions during triage or in EMS?
Now, some facilities may be different, but I get looked at like I have 3 arms when I ask the nurses for the ophthalmoscope head. They certainly don't have the training to perform a fundoscopic exam, and if they did one, I wouldn't trust it. It certainly isn't something EMS would perform.
What about bp, etc?
Valid, if you have a cuff that fits correctly
What happened before the IV was placed? Was IV access ordered prior to even seeing the pt? Those were just some of the things I was considering; if the pt was calm enough to get an IV placed, wouldn't he be calm enough to have his eyes looked at?
Lots of IVs are placed without us ordering them. Less frequently on kids, but still, nursing likes to take charge frequently.
Also, getting a kid to be calm is one thing, getting them to follow commands during an eye exam (or to not move their eyes, or keep them open while you shine a bright light in there) is another.
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
Now, some facilities may be different, but I get looked at like I have 3 arms when I ask the nurses for the ophthalmoscope head. They certainly don't have the training to perform a fundoscopic exam, and if they did one, I wouldn't trust it. It certainly isn't something EMS would perform.
By "eye impressions", I'm just referring to basic things such as dilation, reactivity, palsy, etc. that should be within the scope of EMS and Triage Nurses with penlights. If you were about to see a ped c/o head injury from fall with AMS, wouldn't someone have a GCS for you? If there is CHI concern though, someone qualified to check for fluid and nerve inflammation should probably do one before a head ct (unless your facility has portable ct).
Valid, if you have a cuff that fits correctly
Dude, I'm not sure if I understood you correctly; what's a facility without the ability to get the bp of a ped doing with accreditation for seeing peds?
Lots of IVs are placed without us ordering them. Less frequently on kids, but still, nursing likes to take charge frequently.
I agree, but Head Injury+AMS+Ped, wouldn't you want to at least have a look before or while a nurse is trying to get a line? Also, wouldn't certain factors such as GCS, vomiting, etc. also help you determine whether you would be calling consults?
Also, getting a kid to be calm is one thing, getting them to follow commands during an eye exam (or to not move their eyes, or keep them open while you shine a bright light in there) is another.
I'm certainly not saying it would be easy, especially on a 2yo, but if the circumstances warrant suspicion of pathologies that raise ICP, someone's going to have to do one.
 

Rendar5

15+ Year Member
Nov 12, 2003
6,990
615
381
Florida
Status
Attending Physician
I'm certainly not saying it would be easy, especially on a 2yo, but if the circumstances warrant suspicion of pathologies that raise ICP, someone's going to have to do one.
Have you ever done or attempted to do a fundoscopic exam on a 2 year old? If so, how do you do it? I like to do eye exams when I can for practice, but I've never been able to see a fundus on anyone under maybe 8 years old before due to lack of cooperation?
 

EM2BE

Elf
10+ Year Member
7+ Year Member
Apr 6, 2006
10,622
5
141
Somewhere over the rainbow
Status
Resident [Any Field]
Have you ever done or attempted to do a fundoscopic exam on a 2 year old? If so, how do you do it? I like to do eye exams when I can for practice, but I've never been able to see a fundus on anyone under maybe 8 years old before due to lack of cooperation?
Makes me feel better. I was starting to think I was the only one without the skills to do these exams on the little ones. I would love any tricks anyone has to offer if they've been successful.
 

Stitch

Jedi Ninja Wizard
Moderator
15+ Year Member
Dec 12, 2002
5,594
104
481
Texas
Status
Attending Physician
Have you ever done or attempted to do a fundoscopic exam on a 2 year old? If so, how do you do it? I like to do eye exams when I can for practice, but I've never been able to see a fundus on anyone under maybe 8 years old before due to lack of cooperation?
You can't. :p

I can get a good exam on a cooperative 4 year old, but I'd say a 2 year old isn't really something you can count on, especially if he's 'agitated' as described. In essence, I don't think the exam is going to be all that helpful and you shouldn't base your decision on whether to scan or not on whether you can get a fundoscopic exam.
 

Stitch

Jedi Ninja Wizard
Moderator
15+ Year Member
Dec 12, 2002
5,594
104
481
Texas
Status
Attending Physician
I agree, but Head Injury+AMS+Ped, wouldn't you want to at least have a look before or while a nurse is trying to get a line? Also, wouldn't certain factors such as GCS, vomiting, etc. also help you determine whether you would be calling consults?
This age group (2 and under) is notoriously hard to get a handle on. The question of who to scan and when can be debated ad nauseum. It mostly comes down to your clinical suspicion. I always ask the parents 'how's he acting?' They know their kid better than you do. A 2 year old who hates you, and makes it known that he hates you, is probably fairly healthy. The kid who doesn't care if you poke/prod/start an IV, should get your attention.

In terms of optho exams, I look for the initial things you mentioned: reactivity, will he track the light, can I get him to look at his parents. Turn out the light so it's fairly dark and give yourself as much chance to see something, but I don't always get a good fundal look and it doesn't really matter.
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
Just so we're all on the same page (for those of you who don't read the whole thread! ;) ), I'm not advocating an optho exam on every single pt in every single case. I was referring to this particular instance posted by the OP, where there could have been ICP concerns (only because some people were mentioning that they'd avoid Ketamine because it may cause morbidity if ICP was elevated), and the pt presented with AMS, accompanied potentially with a low enough GCS where ICP-raising pathology was suspected, I posited that an optho exam would be appropriate because it could demonstrate presence of ICP, which would potentially change management. The exam, on this particular pt, if ICP was suspected, would be appropriate, and at that point should have been done prior to when the pt became agitated, at which point it may've made more sense to do. I'm in no way saying that an Optho exam is necessary on any ped that hits their head, but if you reasonably suspect ICP issues, the optho exam is one of the best ways to check for it if conditions permit.
 

Rendar5

15+ Year Member
Nov 12, 2003
6,990
615
381
Florida
Status
Attending Physician
Just so we're all on the same page (for those of you who don't read the whole thread! ;) ), I'm not advocating an optho exam on every single pt in every single case. I was referring to this particular instance posted by the OP, where there could have been ICP concerns (only because some people were mentioning that they'd avoid Ketamine because it may cause morbidity if ICP was elevated), and the pt presented with AMS, accompanied potentially with a low enough GCS where ICP-raising pathology was suspected, I posited that an optho exam would be appropriate because it could demonstrate presence of ICP, which would potentially change management. The exam, on this particular pt, if ICP was suspected, would be appropriate, and at that point should have been done prior to when the pt became agitated, at which point it may've made more sense to do. I'm in no way saying that an Optho exam is necessary on any ped that hits their head, but if you reasonably suspect ICP issues, the optho exam is one of the best ways to check for it if conditions permit.
Again, though, how do you do a fundoscopic exam on a 2 year old? That is why I ask if you've ever done one before in this age group because with the exception of checking for a red reflex, reactivity, and extraocular movements, I don't know how to do a full opthalmologic exam on any 2 year old kid, forget an agitated one (since the purpose in this case is to look for papilledema). If you have successfully done this before, I would love to know your trick.
 

Stitch

Jedi Ninja Wizard
Moderator
15+ Year Member
Dec 12, 2002
5,594
104
481
Texas
Status
Attending Physician
If you have successfully done this before, I would love to know your trick.
Me too. I'm actually not sure why this topic has become such a talking point, and I suspect you (Dimoak) are putting a bit too much faith in a fundal exam, even if you could get one. It's unlikely to change your management even if you could get it (which neither you nor anyone else will be able to). It's really not going to change your management, as these decisions should be made clinically. Based on the presentation, this kid deserves some radiation.

Moreover I've seen a number of kids without papilledema who had significant intracranial pathology, including a midline shift. Papilledema takes some time to show itself. I don't know if that's a kid thing or not, but overall a 'normal' fundal exam, by me, not an ophthalmologist, wouldn't make me not scan this kid who has AMS, agitation or any other sign of trouble. In fact, if you look at the PCARN study (and thank you southerndoc for fixing my link!) which reviewed 44,000 cases of head trauma, they don't even mention ophthalmic exams.
 

greytmedic

Faster than you
10+ Year Member
Dec 17, 2005
313
2
241
California
Status
Resident [Any Field]
I'm on my neuro rotation and we were just discussing papilledema the other day. We were told by a neurophthalmologist that papilledema takes about 12-24 hours to present and my not even be evident for up to 48 hours depending on the degreee of increase in ICP. I don't have any studies to post to back this up but this guy is a well respected academic stud so I'm taking his word.
 

iridesingltrack

10+ Year Member
5+ Year Member
Dec 28, 2007
139
0
0
Status
Fellow [Any Field]
Me too. I'm actually not sure why this topic has become such a talking point, and I suspect you (Dimoak) are putting a bit too much faith in a fundal exam, even if you could get one. It's unlikely to change your management even if you could get it (which neither you nor anyone else will be able to). It's really not going to change your management, as these decisions should be made clinically. Based on the presentation, this kid deserves some radiation.

Moreover I've seen a number of kids without papilledema who had significant intracranial pathology, including a midline shift. Papilledema takes some time to show itself. I don't know if that's a kid thing or not, but overall a 'normal' fundal exam, by me, not an ophthalmologist, wouldn't make me not scan this kid who has AMS, agitation or any other sign of trouble. In fact, if you look at the PCARN study (and thank you southerndoc for fixing my link!) which reviewed 44,000 cases of head trauma, they don't even mention ophthalmic exams.

Agree with above. Personally, I would not feel comfortable basing my medical decision making on an undilated fundus exam. Idiopathic intracrainial hypertension sure...trauma, no way.

It should be noted that cushings triad are also very late signs. If you see these findings, the pt is actively herniating and you are already behind the 8-ball. This patient would need opitimized non-op treatment of ICP and a neurosurgeon.

FWIW, I'd consider fentanyl 1mcg/kg. Quick on, treats the pts pain which is likely related to the agitation, and if you need them, NSGY will appreciate a short acting agent to facilitate their exam.
 
Last edited:

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
Again, though, how do you do a fundoscopic exam on a 2 year old? That is why I ask if you've ever done one before in this age group because with the exception of checking for a red reflex, reactivity, and extraocular movements, I don't know how to do a full opthalmologic exam on any 2 year old kid, forget an agitated one (since the purpose in this case is to look for papilledema). If you have successfully done this before, I would love to know your trick.
No, I have never done one, nor do I have the expertise to do one effectively on a 2 year old. But someone with that ability can do it if the patient is in a state where ICP is suspected. Don't forget the above connotation of my posts, which involved a level of distress where the ICP is high enough to contraindicate Ketamine (which would have to be quite high), and at that point, the patient is probably not going to be easily agitatable. Also, at that point, a successful ophtho exam would probably show edema and optic nerve inflammation to demonstrate the presence of the ICP. If you can't get the ophtho exam, as Stitch alluded to, you probably don't need one. At which point, the patient's ICP levels, as I mentioned earlier in this thread, would not warrant eliminating Ketamine from potential sedatives.

Me too. I'm actually not sure why this topic has become such a talking point, and I suspect you (Dimoak) are putting a bit too much faith in a fundal exam, even if you could get one. It's unlikely to change your management even if you could get it (which neither you nor anyone else will be able to). It's really not going to change your management, as these decisions should be made clinically. Based on the presentation, this kid deserves some radiation.

Moreover I've seen a number of kids without papilledema who had significant intracranial pathology, including a midline shift. Papilledema takes some time to show itself. I don't know if that's a kid thing or not, but overall a 'normal' fundal exam, by me, not an ophthalmologist, wouldn't make me not scan this kid who has AMS, agitation or any other sign of trouble. In fact, if you look at the PCARN study (and thank you southerndoc for fixing my link!) which reviewed 44,000 cases of head trauma, they don't even mention ophthalmic exams.
Once again, I'm not discussing whether or not this patient should or should not have been imaged (they should). The entire point of my posts was that if the patient is indeed in a situation of severe enough distress where the ICP is so elevated that Ketamine should not be used, this would be evident in an optho exam because by then most likely the papilledema and swelling of the optic nerve would be present, as well as other signs such as Cushing's triad. At no point was I arguing that the ophtho exam is an appropriate avenue instead of imaging this patient! My point, simply, was that nothing about the presentation of this patient suggested that Ketamine should not be used to sedate this patient for a head CT; because if the contraindications (highly elevated ICP) were present, there would potentially be a multitude of clinical identifiers prior to the head CT findings, which would have demonstrated a need to address it immediately.
 

xaelia

neenlet
15+ Year Member
Aug 17, 2002
2,126
281
381
PDX
emlitofnote.com
Status
Attending Physician
Dude, I'm not sure if I understood you correctly; what's a facility without the ability to get the bp of a ped doing with accreditation for seeing peds?
Blood pressure is not part of the routine vital signs our facility gets on young pediatric cases. I do not recall the age cutoff. It can be requested on an as-needed basis.

In pediatric ophthalmology, children with significant pathology and the inability to cooperate with examination are booked to the OR for examination under anesthesia.

This thread made me think WTF would I do for corneal/conjuctival FB in a raging child. I wonder if the nystagmus from IM ketamine would be too significant....
 

Stitch

Jedi Ninja Wizard
Moderator
15+ Year Member
Dec 12, 2002
5,594
104
481
Texas
Status
Attending Physician
This thread made me think WTF would I do for corneal/conjuctival FB in a raging child. I wonder if the nystagmus from IM ketamine would be too significant....
I put propiricaine drops in and then let him calm down and try the fluroscene exam.
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
Blood pressure is not part of the routine vital signs our facility gets on young pediatric cases. I do not recall the age cutoff. It can be requested on an as-needed basis.
Ah thanks, I didn't realize that's what Ninja may've meant. I was just confused about why it would be difficult to get a ped's bp if necessary.
 

emedpa

GlobalDoc
10+ Year Member
15+ Year Member
Aug 25, 2001
6,014
301
381
Taking an Away team....
Status
Post Doc
This thread made me think WTF would I do for corneal/conjuctival FB in a raging child. I wonder if the nystagmus from IM ketamine would be too significant....
I have used IM ketamine for both corneal abrasions and embedded fb's in kids without problems.
 

NateintheED

10+ Year Member
5+ Year Member
Jul 24, 2006
91
1
0
Germany
Status
Attending Physician
I'm surprised nobody has yet mentioned Propofol, if the child already has an IV. If you want quick on/off to facilitate neuro exam, its pretty hard to beat, and no ICP concerns. With a 64 (or even 16)-slice scanner, if you're just doing the head, it should be 1-2 minutes, tops, with a good tech. Go to CT, push the propofol, do the scan, and come back. Child is awake again minutes after you get back. Of course, anesthesia at my shop says I can't use propofol, which makes me :mad::mad::mad:

Anyone else with thoughts on propofol?
 

Jarabacoa

non carborundum ilegitemi
10+ Year Member
Mar 24, 2005
906
24
251
Status
Attending Physician
I can't think of a better drug than propofol. I've used IM and IV versed and got the paradoxical agitation with it, leading to me deciding to use propofol which worked like a charm.

Is propofol "approved" (not that FDA approval is the end all be all of clinical decision making) for use in sedating children? This may influence the decision to use it less frequently. This is a wonderful study waiting to happen... sedation in pediatrics for head CT with head to head versed and propofol.
 

Stitch

Jedi Ninja Wizard
Moderator
15+ Year Member
Dec 12, 2002
5,594
104
481
Texas
Status
Attending Physician
I'm surprised nobody has yet mentioned Propofol, if the child already has an IV. If you want quick on/off to facilitate neuro exam, its pretty hard to beat, and no ICP concerns. With a 64 (or even 16)-slice scanner, if you're just doing the head, it should be 1-2 minutes, tops, with a good tech. Go to CT, push the propofol, do the scan, and come back. Child is awake again minutes after you get back. Of course, anesthesia at my shop says I can't use propofol, which makes me :mad::mad::mad:

Anyone else with thoughts on propofol?
I agree it's a great drug and would be ideal. We're not allowed to use it either, so I didn't mention it as an option.

I don't think it's technically approved in kids for sedation, but haven't looked recently. That said, many drugs we use in kids aren't approved in general so I don't know if that would make much difference.
 

DrMom

Official Mom of SDN
Moderator Emeritus
10+ Year Member
15+ Year Member
Apr 24, 2002
43,317
21
251
wherever I go, there I am
Status
Attending Physician
They refuse to give it IM.
We have a testy bunch here.
I have to push it myself, IV or IM, at the large community hospital where I moonlight.
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
Pediatric Patients: Most patients aged 3 years through 16 years and classified ASA-PS I or II require 2.5 to 3.5 mg/kg of DIPRIVAN Injectable Emulsion for induction when unpremedicated or when lightly premedicated with oral benzodiazepines or intramuscular opioids. Within this dosage range, younger pediatric patients may require higher induction doses than older pediatric patients. As with other sedative-hypnotic agents, the amount of intravenous opioid and/or benzodiazepine premedication will influence the response of the patient to an induction dose of DIPRIVAN Injectable Emulsion. A lower dosage is recommended for pediatric patients classified as ASA-PS III or IV. Attention should be paid to minimize pain on injection when administering DIPRIVAN Injectable Emulsion to pediatric patients. Boluses of DIPRIVAN Injectable Emulsion may be administered via small veins if pretreated with lidocaine or via antecubital or larger veins
Indication Approved Patient Population
Initiation and maintenance of Monitored Anesthesia Care (MAC) sedation Adults only
Combined sedation and regional anesthesia Adults only
Induction of General Anesthesia Patients ≥ 3 years of age
Mainenance of General Anesthesia Patients ≥ 2 months of age
Intensive Care Unit (ICU) sedation of intubated, mechanically ventilated patients Adults only
http://www.rxlist.com/diprivan-drug.htm
 

xaelia

neenlet
15+ Year Member
Aug 17, 2002
2,126
281
381
PDX
emlitofnote.com
Status
Attending Physician
Refuse to give based on a few patients with CSF shunts who had elevated ICP after being given ketamine? Or just refuse because "somebody told me ketamine was bad with head injuries?"
Specific case was a screaming two year-old with an angulated femur fracture. I wanted IM ketamine for pain control + sedation so our nurses could get access, and for radiology.

45 minutes later, the nurses have an IV and the kid finally gets his first analgesia. Between all the hand-waving, foot-dragging, nursing-supervisoring going on behind the scenes, I never even had the opportunity to give him some IM morphine while nursing was trying to circumvent me. Do I understand their objections? Yes. Were they doing the right thing for the patient? Good thing two year-olds don't fill out customer satisfaction surveys.

Another random idea I had once upon a time after hearing about low-dose ketamine infusions in multisystem trauma, after orthopedic procedures etc., was whether low-dose ketamine infusion in our sickle cell crisis population could reduce any measures of outcome morbidity. Haven't seen any literature on that topic.
 

iridesingltrack

10+ Year Member
5+ Year Member
Dec 28, 2007
139
0
0
Status
Fellow [Any Field]

Dimoak, You are correct that is what the drug is "approved" for. However, pediatric intensivists use it for maintanance with ventilated pts for up to 24 hrs to facilitate extubation. It is commonly used as an induction agent in pediatric anesthesia. Many EDs use it for procedural sedation. Off label use of meds is common.

However, in this scenario I think that propofol is a pretty big gun. You have a pissed off 2 y/o after an IV, essentially normal behavior for this age. I'd advocate for treating pain, encourage bedside parental soothing and try to scan her. From my take on this the risk of procedural sedation out weighs the benefit...unless all other avenues have failed; though, I may be underestimating the severity of the agitation/injury based on the limited history.

Versed v. Propofol:
http://www.med.umn.edu/peds/em/prod/groups/med/@pub/@med/@peds/@emergmed/documents/content/med_content_127325.pdf


Propofol v. Ketamine:
http://utenti.unife.it/giampaolo.garani/Sedazione-Farmaci/Comparison of Propofol-Fentanyl Versus Ketamine-Midazolam for Brief Orthopedic Procedural Sedation in a Pediatric Emergency Department -- Godambe et al_ 112 (1) 116 -- Pediatrics.pdf


To the OP: what did you end up doing? What did the CT show?
 

Dimoak

Member
10+ Year Member
May 2, 2006
890
11
251
Chicagoland
Status
Dimoak, You are correct that is what the drug is "approved" for. However, pediatric intensivists use it for maintanance with ventilated pts for up to 24 hrs to facilitate extubation. It is commonly used as an induction agent in pediatric anesthesia. Many EDs use it for procedural sedation. Off label use of meds is common.
Yeah, I was just providing that data as a possible point of reference; I'm not familiar with the literature regarding its dosing beyond that. I wonder though, if something did go wrong with the induction dose, couldn't you get slammed at trial with this by an expert witness testifying that it's not indicated for induction of pts younger than 3yo (especially with the high profile of Propofol in the general public)?
 

NateintheED

10+ Year Member
5+ Year Member
Jul 24, 2006
91
1
0
Germany
Status
Attending Physician
Yeah, I was just providing that data as a possible point of reference; I'm not familiar with the literature regarding its dosing beyond that. I wonder though, if something did go wrong with the induction dose, couldn't you get slammed at trial with this by an expert witness testifying that it's not indicated for induction of pts younger than 3yo (especially with the high profile of Propofol in the general public)?
Since I suggested the propofol, I'll chime in here. In the scenario we're discussing we're not using propofol for induction of general anesthesia, which requires a dose high enough for the patient to lose airway reflexes. We're using it for procedural sedation, thus a lower dose would be used (say, 1mg/kg). It seems to me that in this situation, we've already decided that the kid will NOT hold still for CT and so needs to be sedated. The question is which drug. Also, there is plenty of good literature on the safety of propofol for pediatric sedation in the ED.

The package insert contributes to one of the fallacies of logic that the anesthesiologists use to block us from using propofol in the ED at all. The package insert says that only anesthesia providers should use it "when providing MAC or general anesthesia" or something like that. The anesthesia people always seem to conveniently leave out the last part. We're not doing MAC or general. We're doing moderate or deep sedation. The ASA even has a position statement on their website drawing the distinction between these categories. Can you tell I've been trying to fight this battle recently?