Sedation and Analgesia for Pediatric Fracture Reduction in the Emergency Department: A Systematic Review | Anesthesiology | JAMA Pediatrics | JAMA Network
[Skip to Navigation]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Landin  LA Epidemiology of children’s fractures  J Pediatr Orthop B 1997;679- 83PubMedGoogle ScholarCrossref
Lyons  RASellstrom  EDelahunty  AMLoeb  MVarilo  S Incidence and cause of fractures in European districts  Arch Dis Child 2000;82452- 455PubMedGoogle ScholarCrossref
Stark  ADBennet  GCStone  DHChishti  P Association between childhood fractures and poverty: population based study  BMJ 2002;324457PubMedGoogle ScholarCrossref
Cheng  JCNg  BKSing  SYLam  PK A 10-year study of the changes in the pattern and treatment of 6,493 fractures  J Pediatr Orthop 1999;19344- 350PubMedGoogle Scholar
Fosnocht  DEHeaps  NDSwanson  ER Patient expectations for pain relief in the ED  Am J Emerg Med 2004;22286- 288PubMedGoogle ScholarCrossref
Brown  JCKlein  EJLewis  CWJohnston  BDCummings  P Emergency department analgesia for fracture pain  Ann Emerg Med 2003;42197- 205PubMedGoogle ScholarCrossref
Cimpello  LBKhine  HAvner  JR Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients  Pediatr Emerg Care 2004;20228- 232PubMedGoogle ScholarCrossref
Friedland  LRKulick  RM Emergency department analgesic use in pediatric trauma victims with fractures  Ann Emerg Med 1994;23203- 207PubMedGoogle ScholarCrossref
Petrack  EMChristopher  NCKriwinsky  J Pain management in the emergency department: patterns of analgesic utilization  Pediatrics 1997;99711- 714PubMedGoogle ScholarCrossref
Wilson  JE Oligoanalgesia in the emergency department  Am J Emerg Med 1989;7620- 623PubMedGoogle ScholarCrossref
Krauss  BZurakowski  D Sedation patterns in pediatric and general community hospital emergency departments  Pediatr Emerg Care 1998;1499- 103PubMedGoogle ScholarCrossref
Kennedy  RMLuhmann  JDLuhmann  SJ Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children  Paediatr Drugs 2004;611- 31PubMedGoogle ScholarCrossref
Bratt  HDEyres  RLCole  WG Randomized double-blind trial of low- and moderate-dose lidocaine regional anesthesia for forearm fractures in childhood  J Pediatr Orthop 1996;16660- 663PubMedGoogle ScholarCrossref
Davidson  AJEyres  RLCole  WG A comparison of prilocaine and lidocaine for intravenous regional anaesthesia for forearm fracture reduction in children  Paediatr Anaesth 2002;12146- 150PubMedGoogle ScholarCrossref
Godambe  SAElliot  VMatheny  DPershad  J Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department  Pediatrics 2003;112116- 123PubMedGoogle ScholarCrossref
Kennedy  RMPorter  FLMiller  JPJaffe  DM Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies  Pediatrics 1998;102956- 963PubMedGoogle ScholarCrossref
Havel  CJStrait  RTHennes  H A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department  Acad Emerg Med 1999;6989- 997PubMedGoogle ScholarCrossref
Pierce  MCFuchs  S Evaluation of ketorolac in children with forearm fractures  Acad Emerg Med 1997;422- 26PubMedGoogle ScholarCrossref
Evans  JKBuckley  SLAlexander  AHGilpin  AT Analgesia for the reduction of fractures in children: a comparison of nitrous oxide with intramuscular sedation  J Pediatr Orthop 1995;1573- 77PubMedGoogle ScholarCrossref
Gregory  PRSullivan  JA Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation  J Pediatr Orthop 1996;16187- 191PubMedGoogle ScholarCrossref
McGrath  PJJohnson  GGoodman  JTSchillinger  JDunn  JChapman  JA CHEOPS: a behavioral scale for rating postoperative pain in children  Adv Pain Res Ther 1985;9395- 402Google Scholar
Jay  SMElliott  C Behavioral observation scales for measuring children's distress: the effects of increased methodological rigor  J Consult Clin Psychol 1984;521106- 1107PubMedGoogle ScholarCrossref
Jay  SMOzolins  MElliott  CHCaldwell  S Assessment of children's distress during painful medical procedures  Health Psychol 1983;2133- 147Google ScholarCrossref
Wattenmaker  IKasser  JRMcGravey  A Self-administered nitrous oxide for fracture reduction in children in an emergency room setting  J Orthop Trauma 1990;435- 38PubMedGoogle ScholarCrossref
Luhmann  JDSchootman  MVoytas  LLuhmann  SJKennedy  RM A comparison of ketamine/midazolam and nitrous oxide/hematoma block for forearm fracture reduction in children Abstract presented at: Pediatric Academic Societies’ Annual Meeting; May 1, 2004; San Francisco, Calif
Sherwin  TSGreen  SMKhan  AChapman  DSDannenberg  B Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? a randomized, double-blind, placebo-controlled trial  Ann Emerg Med 2000;35229- 238PubMedGoogle ScholarCrossref
Wathen  JERoback  MGMackenzie  TBothner  JP Does midazolam alter the clinical effects of intravenous ketamine sedation in children? a double-blind, randomized, controlled emergency department trial  Ann Emerg Med 2000;36579- 588PubMedGoogle ScholarCrossref
Green  SMKrauss  B Clinical practice guideline for emergency department ketamine dissociative sedation in children  Ann Emerg Med 2004;44460- 471PubMedGoogle ScholarCrossref
LeBaron  SZeltzer  L Assessment of acute pain and anxiety in children and adolescents by self-reports, observer reports, and a behavior checklist  J Consult Clin Psychol 1984;52729- 738PubMedGoogle ScholarCrossref
January 2006

Sedation and Analgesia for Pediatric Fracture Reduction in the Emergency Department: A Systematic Review

Author Affiliations

Author Affiliations: Divisions of Emergency Medicine (Drs Migita and Klein) and General Pediatrics (Ms Garrison), Department of Pediatrics, University of Washington School of Medicine; Children’s Hospital and Regional Medical Center (Drs Migita and Klein); and Child Health Institute (Ms Garrison), Seattle.

Arch Pediatr Adolesc Med. 2006;160(1):46-51. doi:10.1001/archpedi.160.1.46

Objective  To assess the safety and efficacy of various forms of analgesia and sedation for fracture reduction in pediatric patients in the emergency department, as observed in randomized controlled trials in pediatric populations.

Data Sources  Cochrane Controlled Trials Register, CINAHL (Cumulative Index to Nursing & Allied Health Literature), and MEDLINE. The search terms “fractures,” “manipulation, orthopedic,” “an(a)esthetics,” “analgesics,” and “hypnotics and sedatives” were used.

Study Selection  Studies were included if they were randomized controlled trials studying sedative and/or analgesic regimens for fracture reductions in pediatric patients in the emergency department. The search yielded 915 references. From these, 8 studies inclu ding 1086 patients were selected.

Data Extraction  Interventions studied included intravenous regional blocks (Bier blocks), nitrous oxide, and parenteral combinations. Data on measures of effectiveness and safety were extracted.

Data Synthesis  Ketamine hydrochloride–midazolam hydrochloride was associated with less distress during reduction than fentanyl citrate–midazolam or propofol-fentanyl. Patients receiving ketamine-midazolam required significantly fewer airway interventions than those in whom either fentanyl-midazolam or propofol-fentanyl were used. Data comparing Bier blocks with systemic forms of sedation or analgesia were limited.

Conclusions  Ketamine-midazolam seems to be more effective and have fewer adverse events than fentanyl-midazolam or propofol-fentanyl. Data on other forms of analgesia or sedation are too limited to make comparisons. More research is needed to define the regimen that maximizes safety, efficacy, and efficiency for fracture reduction in pediatric patients.