The correct answer is:

IUntravenous 0.5 – 0.75 mg/kg propafol in combination with 0.5 – 0.75 mg/kg ketamine

Educational Objective:

Discuss procedural sedation in a pediatric trauma patient.

Key Point:

Intravenous ketofol protocols allow for both drugs to be dosed lower than if either is the sole intravenous agent (0.5 - 0.75 mg/kg IV for each instead of at least 1.0 mg/kg IV for each drug).

Also, the combination of ketamine (which has analgesic properties) and propofol (which has sedating properties but lacks analgesic properties) allows for lower dosing of any additional analgesic agent (such as an opioid) as compared to using propofol alone.

Explanation:

The combination of ketamine and propofol (“ketofol”) is favorably mentioned in the 2014 the American College of Emergency Physicians’ clinical policy on sedation and has become a popular option in the recent practice of emergency medicine.

It is thought (but not proven) that propofol and ketamine might offset each other’s side effects. Propofol-associated hypotension and respiratory depression may be reduced by the elevated norepinephrine associated with ketamine. Similarly, the relatively greater risk for ketamine associated nausea and emergence reactions is theoretically reduced by the antiemetic and anxiolytic properties of propofol.

Studies of ketofol show statistically significant benefit in provider satisfaction and sedation quality, along with decreased emesis. Furthermore, ketofol leads to a modest 19% reduction (average of 3 minutes) in pediatric sedation times, as compared to using ketamine alone.

To date, ketofol has NOT been shown to be clinically superior to either agent used alone specifically with regard to respiratory depression or airway complications.

Ketofol provides about 10-15 minutes of sedation time, which can be extended as needed with a half dose of ketofol ((0.2 mg/kg IV is a popular extension dose).

Depending on the context, some practitioners will also extend the sedation time with just propofol because IV propofol has a slightly shorter duration of action (8-10 min) than IV ketamine (15 min).

Propofol alone would not provide analgesia for the laceration repair. Both of the other ketamine choices have incorrect dosing regimens.

Intramuscular ketamine is typically given at a 4-5 mg/kg IM dose; IV Ketamine as a sole agent is usually calculated as1-2 mg/kg IV and gradually administered with titration to effect (less than 1 mg/kg IV may be sufficient).

Note: Multiple recent studies and a meta-analysis have dispelled the notion that ketamine might raise ICP to a dangerous degree in head-injured patients. On the contrary, it appears that ketamine might sometimes improve cerebral blood flow in head-injured patients. The ACEP’s 2014 policy on sedation does not list head injury as a contraindication to using ketamine. If interested, see this 2018 blog of critical care practitioners who discuss the ketamine in head-injury question.

References :

Mace SE,. Procedural sedation and analgesia for the pediatric patient. (Chapter 162) In: Walls R, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed. 2018. 2005-2019.e2

Godwin SA,. Procedural sedation and analgesia. (Chapter 4) In: Walls R, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018. 52-61.e2

Godwin SA, Burton JH, Gerardo CJ, et al; American College of Emergency Physicians. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2): 247-58.