Constantine Erika, Tsze Daniel S, Machan Jason T, Eberson Craig P, Linakis James G, Steele Dale W
From the *Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University, and Section of Pediatric Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital, Providence, RI; †Department of Pediatrics and Division of Emergency Medicine and Pediatrics, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian, New York, NY; Departments of ‡Orthopedics, §Surgery, and ∥Pediatric Orthopedics and Scoliosis, Alpert Medical School of Brown University, Rhode Island Hospital/Hasbro Children's Hospital, Providence, RI.
Pediatr Emerg Care. 2014 Jul;30(7):474-8. doi: 10.1097/PEC.0000000000000164.
Although procedural sedation using intravenous agents is highly effective for forearm fracture reduction, the process is both resource and time intensive. Our objective was to determine whether the use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam reduces (1) pain during the procedure (scored using the Observational Score for Behavioral Distress-Revised score) or (2) the excess sedation time, defined by the time between procedure completion and discharge from sedation. Our secondary outcome measure was total ketamine dose administered during the procedure.
A randomized, double-blind, placebo-controlled clinical trial was conducted. Before fracture reduction, children 3 to 17 years of age randomly received 2% lidocaine (L) or normal saline (NS) into the hematoma of their fracture site during sedation with intravenous ketamine and midazolam.
Ninety patients were randomized: 50 to L and 40 to NS. The groups were similar with regard to age, sex, type of fracture, and prior administration of pain medication. Median Observational Score for Behavioral Distress-Revised scores were 1.11 and 1.69 for the L and NS groups, respectively (P = 0.23). Excess sedation time was not significantly different between the groups (P = 0.36), with a median excess sedation time of 33.0 and 36.0 minutes for the L and NS groups, respectively. Mean ketamine dose administered was not different between the groups (P = 0.42). The mean total dose administered was 1.00 mg/kg and 1.07 mg/kg in the L and NS groups, respectively. Mean midazolam dose was 0.05 mg/kg for both groups.
The use of a hematoma block as an adjunct to procedural sedation with ketamine and midazolam for forearm fracture reduction conferred no additional benefit and did not decrease observed pain scores, excess sedation time, or total ketamine dose administered.
尽管使用静脉药物进行程序性镇静对前臂骨折复位非常有效，但该过程资源和时间消耗大。我们的目的是确定使用血肿内阻滞作为氯胺酮和咪达唑仑程序性镇静的辅助手段是否能降低：（1）操作过程中的疼痛（使用行为痛苦观察评分修订版进行评分），或（2）过度镇静时间，定义为操作完成至镇静后出院之间的时间。我们的次要结局指标是操作过程中氯胺酮的总给药剂量。
进行了一项随机、双盲、安慰剂对照临床试验。在骨折复位前，3至17岁的儿童在静脉注射氯胺酮和咪达唑仑镇静期间，随机在其骨折部位的血肿内注射2%利多卡因（L）或生理盐水（NS）。
90例患者被随机分组：50例接受L组，40例接受NS组。两组在年龄、性别、骨折类型和既往使用止痛药物方面相似。L组和NS组行为痛苦观察评分修订版的中位数分别为1.11和1.69（P = 0.23）。两组间过度镇静时间无显著差异（P = 0.36），L组和NS组的中位数过度镇静时间分别为33.0分钟和36.0分钟。两组间氯胺酮平均给药剂量无差异（P = 0.42）。L组和NS组的平均总给药剂量分别为1.00 mg/kg和1.07 mg/kg。两组咪达唑仑平均剂量均为0.05 mg/kg。
使用血肿内阻滞作为氯胺酮和咪达唑仑程序性镇静的辅助手段用于前臂骨折复位，未带来额外益处，也未降低观察到的疼痛评分、过度镇静时间或氯胺酮总给药剂量。
