Pediatric Emergency Medicine Educational morsels and pearls to help augment comfort when caring for kids. Enhance and refine your understanding of Pediatric Emergency Medicine and augment the care of pediatric patients.
Often clinicians shy away from caring for children, because of the notion that “they aren’t little adults.” We have previously discussed my disdain for this mantra. They are not aliens! They do, however, have different anatomy and physiology that must be taken into consideration. What makes children even more exciting (AKA challenging) to care for is that these differences evolve and change as they grow older. We see this most obviously with respect to Trauma. Take facial trauma for example. Nasal fractures in kids need to be approached differently than in adults. Actually, all of the changing anatomy of a child affects facial fractures considerably. Let us take a minute to digest a morsel of knowledge on Pediatric Facial Fractures and Age:
Facial Fractures: Basics
Facial Fractures occur less commonly in children than adults.
~5-15% of all facial fractures are seen in children. [Alcala-Galiano, 2008]
Lowest rates in infants and increases with age.
Two peaks in frequency of facial fractures: [Alcala-Galiano, 2008]
6-7 years of age (early school age)
12-14 years of age (increased sports participation… and being adolescents)
Most common associated causes: [Alcala-Galiano, 2008]
Motor Vehicle Accidents – ~36% (because cars injure everyone all of the time!) [Wong, 2016; Costa Ferreira, 2016]
Sports Participation – ~26% (Kids colliding at high speeds, or throwing projectiles at each other)
Falls – ~23% (Gravity works always) [Oleck, 2019]
Interpersonal Violence – ~9% (’cause people are terrible to each other) [Hoppe, 2015; Hope, 2014]
Ferreira PC1, Barbosa J, Braga JM, Rodrigues A, Silva ÁC, Amarante JM. Pediatric Facial Fractures: A Review of 2071 Fractures. Ann Plast Surg. 2016 Jan;77(1):54-60. PMID: 25275475. [PubMed] [Read by QxMD]
Facial fractures are infrequent in children and adolescents, and there are only few reports that review a significant number of patients. The objective of this study was to analyze the pattern of maxillofacial fractures in pediatric patients of Portugal. […]
Wong FK1, Adams S, Coates TJ, Hudson DA. Pediatric Facial Fractures. J Craniofac Surg. 2016 Jan;27(1):128-30. PMID: 26674891. [PubMed] [Read by QxMD]
There are few published articles describing the epidemiology of facial fractures in South Africa, and there is only one published study in pediatric patients. […]
Hoppe IC1, Kordahi AM, Lee ES, Granick MS. Pediatric Facial Fractures: Interpersonal Violence as a Mechanism of Injury. J Craniofac Surg. 2015 Jul;26(5):1446-9. PMID: 26106996. [PubMed] [Read by QxMD]
Interpersonal violence is a relatively infrequent cause of injury to the craniofacial skeleton in the pediatric population. The presentation of fractures as a result of different causes varies dramatically and can have a direct impact on management. The current study compares facial fractures in a pediatric population as a result of interpersonal violence with other mechanisms of injury. […]
Hoppe IC1, Kordahi AM, Paik AM, Lee ES, Granick MS. Examination of life-threatening injuries in 431 pediatric facial fractures at a level 1 trauma center. J Craniofac Surg. 2014 Sep;25(5):1825-8. PMID: 25203578. [PubMed] [Read by QxMD]
Pediatric facial fractures represent a challenge in management due to the unique nature of the growing facial skeleton. Oftentimes, more conservative measures are favored to avoid rigid internal fixation and disruption of blood supply to the bone and soft tissues. In addition, the great force required to fracture bones of the facial skeleton often produces concomitant injuries that present a management priority. The purpose of this study was to e […]
Alcalá-Galiano A1, Arribas-García IJ, Martín-Pérez MA, Romance A, Montalvo-Moreno JJ, Juncos JM. Pediatric facial fractures: children are not just small adults. Radiographics. 2008 Mar-Apr;28(2):441-61; quiz 618. PMID: 18349450. [PubMed] [Read by QxMD]
Radiologic imaging is essential for diagnosing pediatric facial fractures and selecting the optimal therapeutic approach. Trauma-induced maxillofacial injuries in children may affect functioning as well as esthetic appearance, and they must be diagnosed promptly and accurately and managed appropriately to avoid disturbances of future growth and development. However, these fractures may be difficult to detect on images, and they are frequently und […]
It is often stated that “not all that Wheezes is Asthma,” but actually recalling what is on that Differential Diagnosis list is challenging. We have discussed several wheeze-related etiologies like Bronchiolitis, Heart Failure, Pneumonia, and Aspirated Foreign Bodies. Similarly, not all Stridor is Croup (ex, Recurrent Croup, RPA, and Tracheitis). Obviously, there are many conditions that need to be considered for these patients presenting with respiratory distress. Let’s take a moment to review one other condition that is often under-appreciated – Paradoxical Vocal Fold Movement:
Ng TT1. The forgotten cause of stridor in the emergency department. Open Access Emerg Med. 2017 Jan 16;9:19-22. PMID: 28144169. [PubMed] [Read by QxMD]
Paradoxical Vocal Fold Movement Disorder is where the larynx exhibits paradoxical vocal cords closure during respiration, creating partial airway obstruction. Causes of vocal fold movement disorder are multifactorial, and patients describe tightness of throat, difficulty getting air in, have stridor, and do not respond to inhalers. We propose using transnasal laryngoscopy examination, which will show narrowing of vocal cords on inspiration, and T […]
Matrka L1. Paradoxic vocal fold movement disorder. Otolaryngol Clin North Am. 2014 Feb;47(1):135-46. PMID: 24286687. [PubMed] [Read by QxMD]
Paradoxical Vocal Fold Movement Disorder (PVFMD) is a cause of dyspnea that can mimic or occur alongside asthma or other pulmonary disease. Treatment with Laryngeal Control Therapy is very effective once the entity is properly diagnosed and contributing comorbidities are managed appropriately. In understanding the etiology of PVFMD, focus has broadened beyond psychiatric factors alone to include the spectrum of laryngeal irritants (laryngopharyng […]
Franca MC1. Differential diagnosis in paradoxical vocal fold movement (PVFM): an interdisciplinary task. Int J Pediatr Otorhinolaryngol. 2014 Dec;78(12):2169-73. PMID: 25455524. [PubMed] [Read by QxMD]
The objective of this study was to contribute to the discussion of differential diagnosis in paradoxical vocal fold movement (PVFM), a disorder frequently associated with episodes of breathing difficulty and stridor. Because of analogous respiratory symptoms, PVFM is often misdiagnosed as asthma. Additional evidence suggests the association of factors such as respiratory struggle during physical exertion, digestive reflux, and respiratory allergi […]
It may not be apparent, but the Ped EM Morsels have been a weekly publication since 2010 (actually really since 2008). They have been published every week since… except for when ugly Spammers crash the servers. This is actually the 457th Morsel posted. All of them have been inspired by actual patient encounters and real clinical questions. Many of my fantastic colleagues and residents at Carolinas Medical Center have helped guide me toward the important topics and questions. Now… this week… I call upon the power of the FOAM community. Take a moment and tell me what CLINICAL Question you would like me to write the next Morsel about! Submit your CLINICAL Question via the Comment function on the website below… or by emailing the question to email@example.com. Let’s see what the next ~450 Morsels bring!
THANK YOU FOR YOUR CONTINUED SUPPORT! I greatly appreciate it!
School is out and Summer is in full swing (at least up here in the Northern Hemisphere) and that means … more pediatric trauma (sadly)! Pediatric Trauma can be very challenging to manage for numerous reasons (many that we have already touched upon within the Morsels). The child’s different anatomy and physiology and their changes that occur relative the patient’s age make the can obscure the potential hazards. Recently, a nice review was published [Acker, 2019] that reminds us to remain vigilant for some of these Pediatric Trauma Pitfalls:
Pediatric Trauma: Some Differences
Trauma is the leading cause of Morbidity and Mortality (M&M) in children (as well as young adults)!
While not aliens, children do have different anatomy and physiology that needs to be accounted for, like:
Serial exams are important, as CT may not show the injury.
Under-appreciating the Potential for NAT
NAT can lead to very dramatic presentations, but can also be subtle – look for sentinel bruising.
Head Injury is the most common and most lethal injury due to NAT.
ANY SUSPICION (not actual diagnosis) needs to be reported to the authorities!
Moral of the Morsel
Pediatric Patients are NOT Aliens! They do, however, have different anatomy and physiology that must be considered!
Pediatric Trauma patients can be even more challenging than adults to evaluate. Remain vigilant and be aware of the presence of the pitfalls!
Acker SN1, Kulungowski AM2. Error traps and culture of safety in pediatric trauma. Semin Pediatr Surg. 2019 Jun;28(3):183-188. PMID: 31171155. [PubMed] [Read by QxMD]
Trauma is the leading cause of morbidity and mortality in the pediatric population. Due to a variety of factors, many pediatric trauma patients are initially evaluated and stabilized at adult hospitals that lack pediatric specific emergency medicine and surgical expertise. While similar to adult patients, the initial evaluation and resuscitation of pediatric patients does differ. Many of these key differences contribute to missed injury and susce […]
Pediatric ECGs are useful screening tools that we like to use for cases of Syncope or Chest Pain. While we may be actively looking for signs of Prolonged QTc,Brugada Sign, WPW, or Pulmonary Embolism, what we may find, instead, is huge voltages that seem to dominate the entire sheet. We’ve discussed the differences that must be accounted for when evaluating the Pediatric ECG previously. Let us take a moment to reiterate the issues to contemplate when considering either Left or Right Ventricular Hypertrophy:
Small chest walls will exaggerate precordial voltages. Know what is normal.
Know the Evans’ Rules! While there are other “rules” for RVH and LVH, the ones described by Evans et al. are very practical.
The ECG generates a DDx not a Dx. Use the ECG as a way to help generate and sort through your Ddx.
Evans WN1, Acherman RJ, Mayman GA, Rollins RC, Kip KT. Simplified pediatric electrocardiogram interpretation. Clin Pediatr (Phila). 2010 Apr;49(4):363-72. PMID: 20118092. [PubMed] [Read by QxMD]
We describe a simplified method for interpreting a pediatric electrocardiogram (EKG). The method uses 4 steps and requires only a few memorized rules, and it can aid health care providers who do not have immediate access to pediatric cardiology services. Most pediatric EKGs are normal. However, both abnormal and normal EKGs should be sent to a pediatric cardiologist for later, confirmatory interpretation. […]
O’Connor M1, McDaniel N, Brady WJ. The pediatric electrocardiogram part III: Congenital heart disease and other cardiac syndromes. Am J Emerg Med. 2008 May;26(4):497-503. PMID: 18410822. [PubMed] [Read by QxMD]
Approximately 1% of newborns are affected by congenital heart disease (CHD), and although many lesions of CHD have trivial hemodynamic and clinical implications, some clinically significant lesions are asymptomatic in the immediate newborn period and may present after discharge from the well baby nursery. Because of this, CHD should be considered in the differential diagnosis of any ill-appearing newborn, regardless of the presence of cyanosis. I […]
O’Connor M1, McDaniel N, Brady WJ. The pediatric electrocardiogram part II: Dysrhythmias. Am J Emerg Med. 2008 Mar;26(3):348-58. PMID: 18358948. [PubMed] [Read by QxMD]
The following article in this series will describe common arrhythmias seen in the pediatric population. Their definitions and clinical presentations along with electrocardiogram (ECG) examples will be presented. In addition, ECG changes seen in acute toxic ingestions commonly seen in children will be described, even if such ingestions do not produce arrhythmias per se. Disturbances of rhythm seen frequently in patients with unrepaired and correct […]
O’Connor M1, McDaniel N, Brady WJ. The pediatric electrocardiogram. Part I: Age-related interpretation. Am J Emerg Med. 2008 Feb;26(2):221-8. PMID: 18272106. [PubMed] [Read by QxMD]
Emergency physicians attending to pediatric patients in acute care settings use electrocardiograms (ECGs) for a variety of reasons, including syncope, chest pain, ingestion, suspected dysrhythmias, and as part of the initial evaluation of suspected congenital heart disease. Thus, it is important for emergency and acute care providers to be familiar with the normal pediatric ECG in addition to common ECG abnormalities seen in the pediatric populat […]
I was always taught to have a very healthy respect for infections of the Hands, Feet, or Face. Certainly, the infection itself can be problematic (tenosynovitis, plantar puncture, sinusitis, otitis media), but those particular areas have lots of very delicate and important structures in extremely close proximity… and that combination can lead to significant complications. Fortunately, the potential complications are rarely encountered. Unfortunately, their rarity may make our consideration of them challenging (ex,Gradenigo’s Syndrome). Let us maintain our reasonable vigilance and discuss another important complication – Cavernous Sinus Thrombosis:
The anatomy of the Cavernous Sinus is important to consider.
It is an irregular shaped space lined with endothelium.
It is on either side of the sella turcica.
It is lateral and superior to the sphenoid sinus.
It is immediately posterior to the optic chiasm.
Venous drainage is from the “Danger Triangle!” [Smith, 2015; Varshney, 2015]
Region from the corners of the mouth to the bridge of the nose and inclusive of the nose and maxilla.
Venous drainage from:
Superior and Inferior Ophthalmic Veins
Sphenoid and Middle Cerebral Veins
Also drainage from frontal sinuses.
The connecting veins to and from the Cavernous Sinus lack valves so blood can flow in either direction… and thrombosis can migrate in both directions. [Varshney, 2015]
Cavernous Sinus Thrombosis
Cavernous Sinus Thrombosis is rare, but life-threatening. [Smith, 2015; Frank, 2015]
Frequency has been reduced since high utilization of antibiotics.
Mortality has been also reduced, but still exists and morbidity can be significant.
Usually a late complication of an infection of the central face. [Varshney, 2015]
Cavernous Sinus Thrombosis is an associated complication of:
Functional Endoscopic Sinus Surgery has been advocated for, but not often required emergently.
Consultation with ENT early is important to help coordinate care for those who are not improving on antibiotics.
Moral of the Morsel
Remain Vigilant! It may be rare… but if there is a mid-face infection and High Fevers, Periorbital Edema, and/or Cranial Nerve abnormalities… think of Cavernous Sinus Thrombosis.
Abx STAT! Get the antimicrobial coverage started… and consider antifungals for at risk patients.
Consult ENT… but don’t expect emergent surgery.
Rodriguez-Homs LG1, Goerlitz-Jessen M1, Das SU1. A 17-Year-Old Girl With Unilateral Headache and Double Vision. J Investig Med High Impact Case Rep. 2019 Jan-Dec;7:2324709619838309. PMID: 31010318. [PubMed] [Read by QxMD]
Tolosa-Hunt syndrome is characterized by a painful ophthalmoplegia secondary to a granulomatous inflammation in or adjacent to the cavernous sinus. Magnetic resonance imaging will show enhancement of the cavernous sinus and/or the orbital apex. Although this syndrome is extremely rare in children, it should be a diagnostic consideration in patients presenting with painful ophthalmoplegia with variable involvement of cranial nerves II to VI. The d […]
Varshney S1, Malhotra M1, Gupta P1, Gairola P1, Kaur N1. Cavernous sinus thrombosis of nasal origin in children. Indian J Otolaryngol Head Neck Surg. 2015 Mar;67(1):100-5. PMID: 25621244. [PubMed] [Read by QxMD]
Cavernous sinus thrombosis is a rare presentation. Early diagnosis and aggressive treatment are required to prevent morbidity and mortality. Nasal infections can give rise to serious intracranial complications. Presented here is a case series of cavernous sinus thrombosis of nasal septic origin. The purpose of this article is to report our experience in pediatric patients with this illness to ascertain a clinical course and outcomes for further c […]
Reid JR1. Complications of pediatric paranasal sinusitis. Pediatr Radiol. 2004 Dec;34(12):933-42. PMID: 15278322. [PubMed] [Read by QxMD]
Acute paranasal sinus infection in children is often diagnosed clinically without the need for radiographic confirmation. Most cases have a favorable outcome following appropriate antibiotic therapy. A small percentage of cases where symptoms and signs are persistent or severe will require emergent imaging to rule out complications related to local spread of disease intraorbitally or intracranially. A strong index of suspicion is required in such […]
In Charlotte, it has been unseasonably HOT and many of us have been considering escaping to the mountains. Maybe not exactly the way these people have, but at least something to help our families cool off. This lead Dr. Cathy Wares (CMC Assistant Program Director Extraordinaire) to ponder just how children are affected by that High Altitude environment. Great question… let us take a minute to explore High Altitude Illness in Children:
High Altitude Illness: Pediatric Considerations
Involvement of children in high altitude environments has been increasing. [Heggie, 2018; Garlick, 2017; Joy, 2015; Moraga, 2002]
Alpine skiing / snowboarding and extreme sports are notable.
Vacations/Visitation to high altitude areas.
Denver, Colorado is ~5,500 feet above sea level.
Breckenridge, Colorado is ~10,000 ft above sea level.
Rocky Mountains are ~10,000 ft above sea level.
Hypobaric Hypoxia leads to the physiologic stressors associated with High Altitude Illnesses (HAI).
Distinct from Acute Mountain Sickness by presence of neurologic impairment: [Garlick, 2017]
Ataxia, Confusion, Altered Mental Status
Can follow Acute Mountain Sickness though.
Very rare in children…
Likely related to being rare in adults and…
Primarily occurring at elevations > 13,123 feet (4,000 meters).
Dexamethasone: [Garlick, 2017]
0.15 mg/kg/dose q 6 hrs.
Moral of the Morsel
Kids travel to the highest of heights! Achievement is great… but High Altitude Illness is not!
The Tortoise will beat the Hare! Ascending slowly is the key to prevention!
Know who is at higher risk! Chronic lung conditions are particularly problematic!
Going Home can make some sick! Re-Entrant Pulmonary Edema can be seen in children more than in adults.
Heggie TW1,2, Küpper T3. Pediatric and adolescent injury in wilderness and extreme environments. Res Sports Med. 2018;26(sup1):186-198. PMID: 30431353. [PubMed] [Read by QxMD]
The participation of children and adolescents in wilderness and extreme environment sports is increasing. Engaging in these activities is not without risk of injury, illness, or death. To date, there is limited research investigating pediatric and adolescent injuries in wilderness and extreme environments. With the intent of creating awareness within the sports medicine field, this review begins by examining the growth in popularity of outdoor sp […]
Ryan S1,2, Dudley N3,2, Green M2, Pruitt C3,2, Jackman G4. Altered Mental Status at High Altitude. Pediatrics. 2018 Aug;142(2). PMID: 29976571. [PubMed] [Read by QxMD]
Intrathecal baclofen pumps are commonly used in pediatric patients with spastic cerebral palsy. Baclofen binds to γ-aminobutyric acid receptors to inhibit both monosynaptic and polysynaptic reflexes at the spinal cord level. The blockade stops the release of excitatory transmitters and thereby decreases muscle contraction. It is commonly used for lower limb spasticity and has been shown to improve postural ability and functional status. The US F […]
Joy E1, Van Baak K2, Dec KL3, Semakula B4, Cardin AD5, Lemery J6, Wortley GC7, Yaron M6, Madden C8. Wilderness Preparticipation Evaluation and Considerations for Special Populations. Wilderness Environ Med. 2015 Dec;26(4 Suppl):S76-91. PMID: 26617382. [PubMed] [Read by QxMD]
Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chro […]
A common theme amongst the Ped EM Morsels is remaining vigilant while maintaining a reasonable approach to the care of children. Many devastating conditions can be quite subtle in their initial presentation. Last week, a prior PEM graduate from Carolinas Medical Center, Dr. Simone Lawson joined me to chat about a potentially devastating condition that can easily be, and unfortunately is, often missed at first presentation: Child Abuse. While discussing this critically important topic on EMGuideWire’s Core Concepts (take a listen and consider subscribing – it’s free!) with our Child Protection expert, Dr. Pat Morgan, a useful tool was brought up to help us all not miss the subtle presentation of child abuse. I wanted to reiterate it here. Let’s take a minute to remember the importance of Sentinel Bruising and Abusive Injuries in Children:
Bruising in the Peds ED
Bruising is commonly seen in the Pediatric ED. [Pierce, 2016]
Infrequently is it related to a medical condition (ex, Hemophilia, ITP).
Most often it is related to traumatic complaints (Gravity works!).
Non-accidental Trauma… is Trauma… but can be overlooked easily.
Bruising may be the “sentinel” sign of non-accidental trauma in a child. [Pierce, 2017; Pierce, 2017; Pierce, 2009]
It is known to be under-appreciated in those children who later are found to be severely injured or killed.
28-64% of children who sustain severe physical abuse were found to have had a prior “sentinels” bruise. [Pierce, 2017; Pierce, 2017]
Bruising: Looking for Red Flags
If bruises occur commonly, are often due to explainable accidents, and we often overlook them as they don’t require specific therapy, BUT they can also be the first clue indicating physical abuse is occurring, how can we reasonable remain vigilant?
Look for well known Red Flags!
Bruising characteristics that are concerning for abuse: [Pierce, 2016; Pierce, 2010]
Number of Bruises
More than 3 bruises from one event are uncommonly due to accidents (unless from falls down stairs or MVCs)
Pierce MC1, Kaczor K2, Acker D3, Webb T4, Brenzel A5, Lorenz DJ6, Young A7, Thompson R8. History, injury, and psychosocial risk factor commonalities among cases of fatal and near-fatal physical child abuse. Child Abuse Negl. 2017 Jul;69:263-277. PMID: 28500923. [PubMed] [Read by QxMD]
Failure to recognize child maltreatment results in chronic exposure to high-risk environments where re-injury or death may occur. We analyzed a series (n=20) of fatal (n=10) and near-fatal (n=10) physical child abuse cases from the Commonwealth of Kentucky to identify commonalities and determine whether indicators of maltreatment were present prior to the child’s fatal or near-fatal event. We conducted retrospective state record reviews involving […]
Pierce MC1, Magana JN2, Kaczor K3, Lorenz DJ4, Meyers G5, Bennett BL5, Kanegaye JT2. The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med. 2016 Jan;67(1):1-8. PMID: 26233923. [PubMed] [Read by QxMD]
Bruising can indicate abuse for infants. Bruise prevalence among infants in the pediatric emergency department (ED) setting is unknown. Our objective is to determine prevalence of bruising, associated chief complaints, and frequency of abuse evaluations in previously healthy infants presenting to pediatric EDs. […]
Pierce MC1, Smith S, Kaczor K. Bruising in infants: those with a bruise may be abused. Pediatr Emerg Care. 2009 Dec;25(12):845-7. PMID: 20016354. [PubMed] [Read by QxMD]
Bruising in the young infant is rare, and if present, this may be a manifestation of physical child abuse. Early signs of abuse, such as bruising, are often overlooked or their significance goes unrecognized resulting in poor patient outcomes. In such cases, the opportunity to intervene and potentially prevent repeat injury is lost, and the child is placed back in harm’s way. This brief report presents 3 cases of nonmobile infants who presented t […]
Keeping children comfortable benefits everyone! Patients have less pain and psychological trauma. Their families think you are amazing and… your procedure is easier to do when not also performing professional wrestling maneuvers. Honestly, a successful procedural sedation is one of the best things to do in the ED. It satisfies everyone… which makes for some good job satisfaction while you are driving home. On the other hand… a less than successful sedation is… well, not satisfying at all. Recently, my stellar Pediatric EM Fellows and I were discussing sedation practices. We spoke of Ketamine for pain and sedation and how it can begiven via the nostril route! Nitrouswas also discussed and how it is almost the perfect tool for the job — yet, many are still unfamiliar with it. Then we discussed the nearly omnipresent topic of “Ketofol.” Even this old dog can learn a new trick I suppose… but do I need to? Let’s look briefly at Ketamine and Propofol (Ketofol) for Pediatric Procedural Sedation:
Ketamine and Propofol: A Complementary Pair
Risks and benefits are constantly being weighed in medicine.
Selecting the “best” medicine for procedural sedation is even more challenging as we need to consider appropriate:
Every medicine has potential negative aspects that must be accounted for while hoping to augment the benefits.
While we all LOVE ketamine and propofol, neither Ketamine nor Propofol are perfect.
Has analgesic, amnestic, and dissociative properties!
Relatively fast onset
Airway reflexes are maintained
Supports (and even augments) cardiovascular status
In theory, the combination of the two has potential benefits:
Avoidance of hypotension.
Improved pain control.
Reduced dosage of both medicines.
In practice, the co-administration of ketamine and propofol has been found:
To be safe and effective. [Miller, 2019; Weisz, 2017; Scherer, 2015; Canpolat, 2012; Shah, 2011; Andolfatto, 2010]
To lead to less vomiting. [Shah, 2011]
To have slightly faster recovery times (although perhaps not clinically noticeable). [Shah, 2011]
To lead to good satisfaction. [Andolfatto, 2010]
To have similar adverse event rates with Ketamine alone. [Weisz, 2017]
To lead to less propofol use. [Chiaretti, 2011]
Whether the clinical differences between Ketamine alone and ketofol are substantial enough to warrant the advocacy of ketofol over ketamine is likely to be based on provider experience and preference.
Ketofol: How to…
Two separately administered medicines. [Miller, 2019]
Ketamine (0.5 mg/kg) given first to mitigate pain from propofol injection.
Followed by propofol (0.5 mg/kg).
Additional titrated doses of propofol as required.
Single mixture of both medicine administered concurrently. [Miller, 2019]
Commonly referred to as “ketofol.”
Mixture of ketamine and propofol within the same syringe.
Both ketamine and propofol have the same mg/ml concentration.
Typically used in a 1:1 ratio (same mg/kg dosage), although this is being investigated also.
Moral of the Morsel
Old dogs (like me) can learn new tricks. Sedation, though, shouldn’t be deemed a trick. Always be vigilant and careful!
Ketofol may be the best of both worlds. Yet, it is also not perfect.
Miller KA1, Andolfatto G2, Miner JR3, Burton JH4, Krauss BS5. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med. 2019 May;73(5):470-480. PMID: 30732981. [PubMed] [Read by QxMD]
We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation. […]