Ketamine: Your Go-To for Pediatric ED Sedation

A 5-year-old boy arrives in the emergency department after sustaining a left forearm fracture. His review of systems is notable for upper respiratory symptoms, including a cough. His past medical history includes asthma, and he currently takes Albuterol and Flovent at home. He has no known drug allergies, has never undergone sedation before, and has been NPO for six hours.

So… Is this kid safe for ED sedation?

And more importantly — What sedative would you reach for?

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The First Rule of Procedural Sedation: The safest sedation is no sedation.

Wait, what? Does that mean we should never sedate anyone?

Of course not. Appropriate procedural sedation and analgesia should not be withheld from a patient. But you, as the sedation provider, must weigh the risks and benefits of sedation for that specific procedure for that specific child. What works for one child may not work for another. Sometimes you are the appropriate person to provide sedation for a child, and other times –  depending on comorbidities, type and duration of procedure, and depth of sedation needed (among other factors) – a higher level of care may be warranted.

In the pediatric ED, where we frequently care for children in need of painful procedures (like fracture reduction, abscess I&D, and foreign body removal) ketamine is often the MVP.

• In a prospective cohort of 6,295 children undergoing procedural sedation in pediatric EDs, ketamine alone had the lowest incidence of serious adverse events (SAE) (0.4%) and significant interventions (0.9%). Propofol had a higher risk of SAE than ketamine alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1). The following combinations increased the of SAE compared to ketamine alone: ketamine and fentanyl (3.2%; OR, 6.5; 95% CI, 2.5-15.2); ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7).
  

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Why We Love Ketamine in the ED

✅ Pros	❌ Cons
Maintains airway tone & drive	Hypersalivation
Preserves BP	Emergence reaction
Provides both analgesia & sedation	Emesis, especially without Zofran
Bronchodilation (great for asthma!)	Contraindicated in schizophrenia, ischemic heart disease, infants <3mo

Mechanism: NMDA receptor antagonist, blocks glutamate and reuptake of catecholamines.

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Dosing Basics

Use	IV Dose	IM Dose
Dissociative Sedation	1–1.5 mg/kg	3–4 mg/kg
Subdissociative (Analgesic)	0.3–0.5 mg/kg	1–2 mg/kg

• Caution combining with fentanyl (↑ SAE risk x6.5) or propofol (↑ SAE risk x4.4).
  
• Glycopyrrolate/Atropine? ↑ risk of respiratory events.
  
• Zofran? Yes — but NNT = 13 to prevent vomiting.
  

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URI and procedural sedation: Should We Worry?

You’ve heard it said — don’t sedate kids with URIs, right?

Here’s the data:

• Among 6,292 kids undergoing procedural sedation, 444 had a URI (cough or rhinorrhea).
  
  • Those with URI had no increased risk of respiratory adverse events or serious respiratory interventions 

• Another study showed the rate of major airway events (e.g. laryngospasm, aspiration) stayed <1%, regardless of URI status.
  

Bottom Line: Presence of URI is not an automatic contraindication. Be cautious — especially with thick/green mucus and active cough — but if a child needs to be sedated for an urgent or emergent procedure in the ED, and especially for brief, painful procedures, would reach for ketamine above other drugs.

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Final Takeaways

• Most pediatric ED procedures are brief, painful, and high-anxiety.
  
• Ketamine alone is one of the safest drugs we use in the pediatric ED for sedation.
  
• Presence of URI is not a contraindication to ED procedural sedation

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Editor’s Note: This new study (published June 2025), the largest study of ketamine as a sole agent for ED pediatric procedural sedation, looked at the frequency and predictors of critical and high-risk adverse events. Spoiler alert: serious adverse events are RARE. Want a full summary? Check out this JournalFeed post. ~JB