Ketamine

This drug has an excellent track record in procedural sedation for children in emergency medicine from 199822, and appears safer than benzodiazepine/opioid combinations23.

Ketamine’s recognised side effects and their reported incidence are reported in Table 11, taken from the RCEM guideline. The emergence phenomena described with ketamine are uncommon. They are not reliably prevented with proactive benzodiazepine24,25, but benzodiazepines are recommended in the rare event of significant recovery agitation.

Table 11: Potential complications of ketamine sedation

Airway: Noisy breathing is usually due to airway mal-position and occurs at an incidence of <1%. This can normally be corrected by paying careful attention to optimal airway positioning.
In rare cases mild laryngospasm may occur (0.3%). The reported incidence of intubation for laryngospasm is 0.02%. A meta-analysis26 showed that low IM doses of ketamine (<3mg/kg) exhibited significantly less overall airway and respiratory adverse events. There were no occurrences of either laryngospasm or apnoea in the 682 children receiving lower IM doses

Vomiting:  5-10% incidence. This usually occurs during the recovery phase

Lacrimation and salivation: 10%

Transient rash: 10%

Transient clonic movements: <5%

Significant agitation 1.5%