You should again consider alternative strategies to sedation including the role of topical local anaesthetic agents for wound toilet,6-9 and steristrips or glue for wound closure. The role of music,10 hypnosis,11,12 confusing tactile stimuli13 and blowing away pain14 are well described distraction techniques in young children. Information regarding the procedure can also be relayed to the child in the form of a story.15 A game on a parents phone may substitute.
The modern day all-in-one-fix-it is a tablet loaded with Minions or Frozen movies (authors personal opinion). The help of an experienced nurse and capable parent cannot be underestimated. You should consider the use of intranasal diamorphine on presentation for more painful conditions,16 as well as paracetamol and ibuprofen. You might diminish the pain on infiltration of (warmed) local anaesthetics by injecting slowly and using a fine gauge needle.
At risk children
The contraindications to ketamine sedation as listed in the RCEM guideline are illustrated below in Table 9.
With specific regard to fasting, and consistent with your approach to adults, a case-by-case risk benefit assessment is more consistent with the current literature than setting an arbitrary fasting period.17
Table 9: Contraindications to ketamine for procedural sedation19 |
In addition to general contraindications:
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