Ketamine versus nitrous oxide plus intranasal fentanyl for paediatric fracture reduction in the emergency department: a prospective randomised comparison trial

Nitrous oxide (N2O) plus intranasal fentanyl (INF) treatment group This treatment requires a Nurse Practitioner, Registrar or consultant physician. Patients randomised to this group will be given INF 2 µg/kg via laryngeal mask airway (LMA) Intranasal mucosal atomization device 15 mins prior to the procedure. Inhalation N2O will commence via a Matrix Digital mobile device management (MDM) delivery mixer starting at 50% N2O and titrated to a concentration of 70% N2O over 5 mins prior to procedure. This slow titration of N2O decreases the incidence of vomiting using N2O in combination with INF. Ketamine procedural sedation and analgesia (PSA) treatment group For the ketamine sedation a consultant physician, or registrar under the direction of a consultant physician, will be present at the bed side for the procedural sedation. Patients randomised to receive ketamine for PSA will receive an initial dose of 1 to 2 mg/kg IV Ketamine prior to commencement of the procedure. Dose of ketamine provided will be decided by clinician discretion. Topical EMLA (lidocaine 2.5% and prilocaine 2.5%) will be used at the site of injection at least 30 mins prior to IV cannulation to reduce pain at the injection site. Subsequent titrated doses of IV ketamine (0.3 to 0.5 mg/kg) may be administered during the procedure, as deemed necessary by the administering clinician.