Safety of pediatric procedural sedation in a Canadian emergency department.

OBJECTIVE: To assess the safety of pediatric procedural sedation performed by emergency physicians working within a structured sedation protocol. METHODS: A retrospective review of all children undergoing emergency department (ED) procedural sedation during a 2-year period after the institution of a structured sedation protocol. RESULTS: 167 children underwent procedural sedation, primarily for orthopedic manipulation, wound management and foreign body removal. Of these, 82% received ketamine, 17% received fentanyl and midazolam and 1% received midazolam alone. Sedation was adequate in all but 6 patients, who required supplemental ketamine for orthopedic manipulation. Vomiting after arousal occurred in 17 children (10%), but no episodes of clinical aspiration occurred. One child became agitated during recovery and another experienced a transient visual hallucination. There were no cases of laryngospasm, apnea or cardiorespiratory compromise, and no mortality or significant morbidity occurred. CONCLUSION: Emergency physicians using a structured sedation protocol can safely perform ED pediatric procedural sedation. Where intravenous access is not already present, intramuscular ketamine, administered in the doses described, is a safe and effective agent for pediatric sedation.

Efficacy of ipecac during the first hour after drug ingestion in human volunteers.

OBJECTIVE: To determine the decrease of drug absorption when syrup of ipecac is administered at various times within one hour of drug ingestion. METHODS: Ten healthy human volunteers were recruited for a four-limbed randomized crossover study. The three experimental limbs consisted of administration of 30 mL syrup of ipecac, at 5, 30, or 60 minutes after ingestion of 3900 mg acetaminophen as 12 x 325 mg tablets with 250 mL room temperature water. The fourth limb served as control. Blood samples were drawn at 0, 0.5, 1.0, 2.0, 3.0, 4.0, 6.0, and 8.0 hours after analgesic ingestion for serum acetaminophen concentration determination by high-performance liquid chromatography. Repeated measures ANOVA and Tukey's HSD tests were used for group comparisons. RESULTS: The area under the serum concentration vs time curve was (mean +/- SD) 206 +/- 48, 67 +/- 37, 183 +/- 78, and 162 +/- 47 mg/L for control, 5, 30, and 60 minutes, respectively. This corresponds to decreases in bioavailability of 67, 11, and 21%. Only the 5-minute group differed significantly from control (p < 0.05). Sedation was observed as a significant adverse effect of ipecac administration. CONCLUSIONS: Our data do not support benefit from ipecac administration at 30 minutes and beyond. Our data suggest that benefit is lost at some point between 5 and 30 minutes. The sedative effect of ipecac may confound the observation of patients who have ingested sedative hypnotic agents.

Cyanide overdose: survival with fatal blood concentration without antidotal therapy.

Cyanide poisoning is an uncommon emergency department problem. It has a high mortality, and specific antidotal therapy can be lifesaving. We describe a 23-year-old man who ingested potassium cyanide and survived without antidotal therapy. His blood cyanide concentration was 4.65 mg/L, which is within the lethal range. The arterial venous oxygen saturation gradient was considered in the decision regarding antidote administration. Our experience underscores the importance of supportive care.