Indications & route of choice
- Painful ED procedures in children requiring dissociation and analgesia: fracture/dislocation reduction, wound exploration and closure, burns dressing, incision and drainage.
- IV ketamine is the preferred route since the 2020 RCEM guideline moved away from routine IM use — titratable, faster onset, faster recovery, and IV access is already available if an adverse event occurs.
- IM ketamine remains a pragmatic option for a senior decision-maker when IV access cannot be obtained, but carries higher rates of vomiting and a longer recovery.
Consider non-pharmacological and alternative options first where appropriate: analgesia, reassurance, distraction, nitrous oxide, intranasal diamorphine, and play therapy — RCEM lists these as alternatives to ketamine sedation.
Contraindications
Absolute / high-risk
- Age under 12 months (many departments apply a higher practical age limit locally).
- Active upper respiratory tract infection, active asthma, or other high laryngospasm risk.
- Abnormal airway, tracheal surgery or stenosis; procedure planned in the mouth or pharynx.
- Significant cardiac disease; intracranial hypertension with CSF obstruction; intra-ocular pathology.
Further cautions
- Previous psychosis; uncontrolled epilepsy; hyperthyroidism; porphyria.
- Previous adverse reaction to ketamine; altered conscious level; intoxication.
- Fasting status alone is not a contraindication — weigh urgency and comorbidity, per RCEM.
Dosing
- IV ketamine 1.0 mg/kg slow IV injection over at least 60 seconds (reduce to 0.6–0.8 mg/kg for shorter/less-stimulating procedures).
- A supplemental dose of 0.5 mg/kg may be given after 5–10 minutes if sedation is inadequate or the procedure runs long.
- Midazolam 0.05–0.1 mg/kg is reserved for severe emergence phenomena — it is not given prophylactically.
- IM ketamine, where used pragmatically, is not specifically dosed by the RCEM 2020 guideline; the commonly cited 4–5 mg/kg range (with 2–4 mg/kg repeat doses) derives from ACEP 2011 literature, not RCEM — attribute doses accordingly and expect a longer, less predictable recovery.
Team, environment & monitoring
Minimum 3 dedicated staff (sedationist, proceduralist, assistant)
Full resuscitation facilities immediately available
Continuous 3-lead ECG
Blood pressure monitoring
Continuous SpO₂
Waveform capnography
Observations recorded at least every 5 minutes
Suction and airway equipment to hand
Laryngospasm drill
Laryngospasm is rare but is the complication to drill for. RCEM's stepwise response:
Reposition the airway
Optimise head position; open and inspect the airway. Larson's manoeuvre — firm bilateral pressure in the notch behind each ear lobe with a jaw thrust — is taught (RCEMLearning) as an early adjunct at this stage.
Gentle suction + high-flow oxygen
Clear secretions gently; apply high-flow oxygen.
Bag-valve-mask, stop the procedure, call for help
Stop what you are doing, ventilate with BVM, and summon senior/anaesthetic assistance early.
SpO₂ <92% — BVM with PEEP, prepare for RSI
Apply PEEP via BVM; prepare rapid sequence induction equipment in case laryngospasm persists.
Persisting stridor — suxamethonium and RSI
If laryngospasm does not resolve, give suxamethonium and proceed to RSI to secure the airway.
Emergence phenomena
- Uncommon in children under 10 years (RCEM cites approximately 1.6%).
- Reduce risk with positive suggestion before sedation and keeping a parent present through induction and recovery.
- Manage significant emergence reactions with midazolam 0.05–0.1 mg/kg — reserved for severe cases, not given routinely.
Recovery & discharge
- Recovery typically takes 60–120 minutes; continue monitoring throughout.
- Discharge criteria: responding appropriately for age, nystagmus resolved, walking unassisted (age-appropriate), normal vital signs, pain adequately addressed.
- Give clear written safety-netting advice to parents/carers, including expected drowsiness and when to seek help.
Pitfalls & pearls
- Do not delay a genuinely needed sedation over fasting time alone — it is not an RCEM contraindication.
- Prepare parents for the dissociative appearance (fixed gaze, nystagmus, random movements) so they are not alarmed.
- Do not give midazolam prophylactically "just in case" — it adds respiratory depression risk for an uncommon problem.
- A laryngospasm drill should be rehearsed by the whole team before the department needs it for real.
Monitoring flow
DOPS pointers
RCEM curriculum: Intermediate/Higher-level procedural skill. What assessors look for at each entrustment level:
| 1 | Observed only — describes contraindications, dosing and the laryngospasm drill. |
| 2a | Performs with supervisor present: correct dose/rate, monitoring set-up, parental preparation. |
| 2b | Manages the sedation episode with supervisor in department, including recovery and discharge. |
| 3 | Anticipates and manages complications including laryngospasm and emergence phenomena. |
| 4 | Independent; teaches and supervises others, leads paediatric sedation governance. |
References
- Thomas S, France J. Ketamine Procedural Sedation for Children in the Emergency Department. Royal College of Emergency Medicine Best Practice Guideline, revised February 2020.
- American College of Emergency Physicians. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation, 2011 (IM dosing literature).
- RCEM Curriculum 2021 — Emergency Medicine Specialty Learning Outcomes.