Ketamine Sedation in Croydon Paediatric Emergency Department for Manipulation of Forearm Fractures
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Authors
V Estlin
H Mackey
E McGuinness
A Hillary
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Issue Date
2025
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Abstract
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Abstract
Background:
Forearm fractures are the most common site of fracture in paediatric patients, the gold standard management for most of these is casting and allowing bones to remodel. However if the angulation of the fracture exceeds remodelling potential, then the fracture should be manipulated early. The BOAST (British Orthopaedic Association) guidelines state that there should be provision to allow manipulation and casting under procedural analgesia and sedation without requiring admission.
Ketamine for procedural sedation in paediatric patients is widely used in other emergency departments (EDs). This study looks to assess whether bringing in intravenous (IV) ketamine sedation will allow earlier definitive management of paediatric forearm fractures and reduce the number of admissions and general anaesthetics for this population at our trust.
Methods:
A retrospective analysis of all paediatric patients presenting to the emergency department with a forearm fracture over a six month period was done. Fractures not requiring intervention or requiring internal fixation were excluded.
Results:
There were 14 patients with forearm fractures that required manipulation under general anaesthesia. Of these 8 patient were admitted to the ward overnight, and 6 were discharged and brought back the next day.
Conclusion:
Ketamine sedation could have allowed early manipulation in the ED and prevention of these admissions and general anaesthetics. Reducing admissions and theatre cases would have a financial benefit for the trust. For paediatric patients not being admitted to hospital or undergoing a general anaesthetic would also be of benefit. Alongside this ketamine sedation allowing earlier reduction would reduce pain for patients, as ketamine provides analgesia itself and once the fracture is realigned there is considerable reduction in pain.
The introduction of IV ketamine sedation has been commenced. An SOP has been created to allow for clear guidance and standardisation of care. There has been teaching for both the paediatric ED nursing staff and the ED registrars, including simulation sessions. Further to this there is a supervision and sign off programme to ensure registrars are competent in paediatric ketamine sedation before performing any without supervision.
A re-audit of paediatric patients presenting with forearm fractures and outcomes will be performed to assess the benefit of the introduction of ketamine sedation.
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