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A Systematic Review

Russell T. Migita, MD; Eileen J. Klein, MD, MPH; Michelle M. Garrison, MPH

Arch Pediatr Adolesc Med. 2006;160:46-51.

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.

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.

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