The correct answer is:
120 mg intravenous ketamine
Educational Objective:
Discuss procedural sedation using just ketamine.
Key Point:
Of the answer choices, ketamine is the only agent that offers sedation, amnesia, and analgesia. The optimum administration is intravenous, as this is expected to have the most rapid onset of action and the shortest duration of action. Intravenous ketamine dosing is 1-2 mg/kg, while intramuscular dosing is 3-4 mg/kg.
Explanation:
The most appropriate application of procedural sedation in this scenario involves the use of analgesia, sedation, and amnesia. Many of the listed agents perform 1 or more of these desired roles. Fentanyl is an excellent analgesic; however, it offers no sedation or amnesia. Similarly, etomidate offers sedation and amnesia without analgesia. Propofol also offers sedation and amnesia without analgesia.
Fentanyl is an ultra potent opioid and dosing is in mcg/kg; thus, the appropriate dose would be 60 mcg, rather than 60 mg.
Etomidate carries additional risks of myoclonus and is ill advised for joint reduction. The dose is 0.1 mg/kg for procedural sedation. The starting dose of propofol is typically 0.5-1 mg/kg.
The combination of ketamine and propofol (“ketofol”) has become a popular combination in the recent practice of emergency medicine. It is thought (but not proven) that the combination of propofol and ketamine might offset each other’s side effects.
References:
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.
Mace SE,. Procedural sedation and analgesia for the pediatric patient. (Chapter 162) In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018. 2005-2019.e2
Godwin SA,. Procedural sedation and analgesia. (Chapter 4) In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018. 52-61.e2
