Procedural sedation and analgesia for reduction of distal forearm fractures in the paediatric emergency department: a clinical survey

Abstract

Objective: Distal forearm fractures frequently require reduction in children. We set out to survey how such fractures are currently reduced at Paediatric Research in Emergency Departments International Collaborative (PREDICT) sites.

Methods: A survey was completed by paediatric emergency physicians at PREDICT sites. Survey questions covered departmental guidelines and resources and individual practice, agents used and limitations of fracture management using case vignettes.

Results: One hundred eleven of 145 (77%) possible surveys were returned. All 12 PREDICT sites have guidelines for the use of nitrous oxide and 11 of 12 for ketamine. Guidelines for other agents are less common and highly variable. The most frequently used procedural sedation and analgesia (PSA) agents were ketamine (27%), nitrous oxide alone (19%) or in combination with intranasal fentanyl (18%) and Bier's block (11%). Most respondents indicated tolerance without reduction in fractures with angulation less than 20° (59%) and 10° (71%) in a 5- and 10-year-old patient, respectively. Most physicians (74%) would reduce up to a 25° angulated fracture in the ED with more displaced fractures being referred to theatre. The 44% of respondents listed the lack of an image intensifier in the ED as a limitation in their ability to reduce fractures.

Conclusion: Paediatric distal forearm fractures are commonly reduced in the surveyed EDs, most commonly under ketamine or nitrous oxide. Areas of improvement include better defined cut-offs for fracture reduction and for referral to theatre, improved differential efficacy of PSA agents, standardised guidelines for PSA and introduction of image intensifiers into more EDs.