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. 2024 Feb 1;40(2):83-87.
doi: 10.1097/PEC.0000000000002993. Epub 2023 Jun 6.

Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department

Carmen D Sulton  1 , Nicholas Fletcher  2 , Joshua Murphy  3 , Scott Gillespie  4 , Rebecca K Burger  1
Affiliations

Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department

Carmen D Sulton et al. Pediatr Emerg Care. .

Abstract

Background: Pediatric forearm fractures are common injuries in the pediatric emergency department (PED). Pediatric procedural sedation (PPS) is often required for forearm fracture reductions and pain control for casting. Bier blocks and hematoma blocks are types of regional anesthesia (RA) procedures that can be performed as a potential alternative to PPS.

Objective: The objective of this study is to compare the safety of RA with that of PPS. We hypothesized that RA has a safety profile that is equal or superior to PPS as well as a shorter duration of treatment in the PED.

Methods: Pediatric emergency department encounters in patients presenting with a diagnosis of radius fracture, ulna fracture, distal "both-bone" fracture, Monteggia fracture, and/or Galeazzi fracture were included. Outcomes of interest included patient adverse events (AEs), sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures.

Results: Propensity matching was performed resulting in 632 well-matched RA-PPS pairs. The PPS cohort had 13% of encounters with at least 1 AE compared with 0.2% in the RA cohort, P < 0.001. The most common AE in the PPS group was hypoxia (9.8%), and the only AE in the RA group was an intravenous infiltrate (0.16%). Within the matched cohorts, PPS required more medications than RA (100% vs 60%, P < 0.001). Ketamine alone was more commonly used in the PPS group than the RA group (86% vs 0.2%, P < 0.001). Propofol was used only in the PPS group. The average duration of treatment was 205 (SD, 81) minutes in the PPS group and 178 (SD, 75) minutes in the RA group ( P < 0.001). There were no reduction failures in either group.

Conclusions: Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions. The AE rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared with PPS.

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Conflict of interest statement

Disclosure: The authors declare no conflict of interest.

References

    1. Wiik AV, Patel P, Bovis J, et al. Use of ketamine sedation for the management of displaced pediatric forearm fractures. World J Orthop . 2018;9:50–57.
    1. Rimbaldo KM, Fauteux-Lamarre E, Babl FE, et al. Deformed pediatric forearm fractures: predictors of successful reduction by emergency providers. Am J Emerg Med . 2021;50:59–65.
    1. Chinta SS, Schrock CR, McAllister JD, et al. Rapid administration technique of ketamine for pediatric forearm fracture reduction: a dose-finding study. Ann Emerg Med . 2015;65:640–648.e2.
    1. Morrison T, Carender C, Kilbane B, et al. Procedural sedation with ketamine versus propofol for closed reduction of pediatric both bone forearm fractures. Orthopedics . 2017;40:288–294.
    1. Goh AXC, Yeo JW, Gao JF, et al. Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review. Emerg Med J . 2022;39:888–896.

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