Is this FOAM heresy I ask myself…, someone in the social media
world suggesting that we should use LESS Special K.
I’ve been reflecting recently on my use of ketamine in the emergency department. Back when I was a registrar I wrote our original protocol for the use of IM ketamine in kids. I think that would have been back in 2001/2002 so roughly about 10 years ago I guess. At that time it was a great step forward particularly in paediatric emergency medicine as we moved on from ‘Brutacaine’ (holding a child down) as a method of achieving painless procedures in children. A dose of 3mg/Kg Ketamine with atropine was fantastic! So what has changed since then?
Well, the first thing that changed was the move to IV ketamine. If you’re still using IM ketamine then I would really suggest making the move to IV. Now, some people say that if you’re going to stab them with a needle to get IV access then you might as well just go for IM. I too used to think this, but to be honest the superior control, more rapid onset and offset means that IV really is the way to go so long as…..
- You are good at getting IV access in kids.
- You have great nursing/play therapy support to help you do it.
- You use EMLA (or equivalent) to facilitate cannulation.
Fortunately I have all of these where I work and that makes getting access a fairly straightforward and relatively distress free process. The evidence base is not perfect here with reviews in the literature and on BestBets being inconclusive. However, I’ve used loads of both and if you want my opinion IV is by far the best and it’s our standard of care in Virchester.
So IV was the way forward and I guess we started going IV in about 2005/2006. We used 1mg/Kg Ketamine IV with atropine for about a year.
What came next?
It was pretty clear that the atropine was superfluous in the vast majority of cases. Sure, ketamine is known to cause hypersalivation, but it’s rarely (if ever in my experience) a problem and IV atropine is not that pleasant. If you are going IV then you can always give it later if you get a problem so routine administration is arguably unnecessary and a BestBet on the subject backed this up. So in the early days we used to draw the atropine up, but never gave it. These days I just check we have it in the cupboard should it be required, but I don’t draw it up into a syringe.
We were pretty slick to be honest. Ketamine sedations were common in the ED and our consultants and trainees became competent (and confident) in its use.
So, what’s happened recently?
A few months ago I was running through the portfolios of our trainees and it became clear that they were struggling to get signed off as competent in Ketamine sedation and this was primarily due to exposure. Many of our ketamine sedations were historically being done to facilitate wound care, cleaning and suturing usually. We’re just not doing it as much as we did and the culprit is LAT gel.
Now LAT gel has been around for ages. Data on its effectiveness has been in the literature since the 90’s (and TAC was around before that) but we did not start using it in the UK until roughly 2009/2010.
It’s amazing stuff.
Basically a mixture of lidocaine, adrenaline and tetracaine it is applied as a gel into the wound and left for 20-30 minutes. I love it for many reasons, but pharmacologically the top two are….
- It works really well!
- It shows you where it has worked because the skin blanches (due to the adrenaline) .
So an effective agent that tells you where it is has worked = marvellous!
In practice this means that we are doing far fewer ketamine sedations than we were a few years ago as the group of patients tolerant of wound care under LAT gel has increased. Initially we were wary of using it in young children (the 2-6 year olds who aren’t that easy to rationalise with), but in reality they are often the group who do fantastically well with a bit of a cuddle, a book to read, and if you need really powerful medications – BUBBLES.
So, if you’re not using LAT gel you may well be exposing children to anaesthetics, pain or sedation that they just don’t need, and that cannot be good. I will happily support anyone who wants to put it into their practice. Read the literature, show them the blog, drop me a line – whatever. I want to know that if I turn up in your ED with my kids that it’s on your formulary as it’s what I would want for them.
Still have doubts? That’s fine, before I completely convince you let’s run through a few FAQs that might have cropped up in your mind…..
Show me a video on ketamine IV
OK – I get Ketamine – what about LAT gel?
This video looks israeli and I have NO idea what they are saying. However, it’s got some really cool music (not) and it shows LAT gel in use.Look for the blanching around the wound which shows the area of anaesthesia – Cool stuff 🙂
Having seen both methods – which would you want to try first for your kid?
Wound care is not just about pain – what about distress?
You’re absolutely right of course. The management of children in the ED is about managing distress just as much as it is about pain – and the two are really quite different. Whilst LAT gel will reduce pain it cannot help you if a child is scared, distressed and uncooperative, in those circumstances you will need sedation to facilitate wound care (or whatever). It is wise to apply Jenner’s rule here (named after one of my superstar colleagues). Jenner’s rule states.. ‘If the child allows you to put LAT gel on without distress they will let you suture them’ and conversely ‘If the child screams like a banshee when you go anywhere near them, then you’ll need more than LAT gel!
Here’s a great tip on how to apply it from Norman Pao
What age groups can you use it in?
We don’t recommend below the age of 12 months to be honest. This is partly a safety issue as you need to be careful in the youngsters, but also because it’s very rare that you would need to do suturing in the ED at this age (what the hell happened to get a wound needing ED suturing you should be asking).
At an age of 1 year you only have 1ml of LAT gel to use (assuming 10Kg) child so there are limits to what can be achieved, and there are other practical issues such as whether they are going to be able to stay still with distraction.
You can of course use it in adults as well, but as it’s more expensive it tends not to be done in practice.
What is the dose?
On our formulary it’s 0.1ml/Kg
Is there a limit in terms of wound size?
We say up to 8cm, but the dosage also limits the size of wound. In small kids you can only use a small amount, so obviously you can only use it on small wounds.
What’s in LAT gel?
In our formulary it is as follows. Each 1ml contains
- Lidocaine Hydrochloride 40mg
- Adrenaline (as acid tartrate) 1mg
- Tetracaine Hydrochloride 5mg
- Sodium Metabisulffite 1mg
- Disodium Edetate 0.1mg
- Hydroxypropylmethylcellulose 20mg
But please check this with your local pharmacist!!! We get ours from Torbay PMU, Paignton, Devon, TQ47TW
Finally, a personal plea. If you’re not currently using LAT gel and this post changes that then please, please, please let me know.If you are using it and agree with me, let me know. If you think I’m talking rubbish, let me know.
It would FOAMtastic if this made a difference. We aspire to a pain free ED. This is one of the tools on that journey and I hope that you embrace it. You and your patients will be grateful if you do.
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