Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies

Pediatrics. 1998 Oct;102(4 Pt 1):956-63. doi: 10.1542/peds.102.4.956.


Objective: Emergency management of pediatric fractures and dislocations requires effective analgesia, yet children's pain is often undertreated. We compared the safety and efficacy of fentanyl- versus ketamine- based protocols.

Methodology: Patients 5 to 15 years of age needing emergency fracture or joint reduction (FR) were randomized to receive intravenous midazolam plus either fentanyl (F/M) or ketamine (K/M). Measures of efficacy were observational distress scores and self- and parental-report. Measures of safety were frequency of abnormalities in and need for support of cardiopulmonary function and other adverse effects.

Results: During FR, K/M subjects (n = 130) had lower distress scores and parental ratings of pain and anxiety than did F/M subjects (n = 130). Although both regimens equally facilitated reductions, deep sedation, and procedural amnesia, orthopedists favored K/M. Recovery was 14 minutes longer for K/M. Fewer K/M subjects had hypoxia (6% vs 25%), needed breathing cues (1% vs 12%), or required oxygen (10% vs 20%) than did F/M subjects. Two K/M subjects required assisted ventilation briefly. More K/M subjects vomited. Adverse emergence reactions were rare but equivalent between regimens.

Conclusions: During emergency pediatric orthopedic procedures, K/M is more effective than F/M for pain and anxiety relief. Respiratory complications occurred less frequently with K/M, but respiratory support may be needed with either regimen. Both regimens facilitate reduction, produce amnesia, and rarely cause emergence delirium. Vomiting is more frequent and recovery more prolonged with K/M.

Publication types

  • Clinical Trial
  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Analgesics, Opioid / adverse effects
  • Analgesics, Opioid / therapeutic use*
  • Anesthetics, Dissociative / adverse effects
  • Anesthetics, Dissociative / therapeutic use*
  • Anti-Anxiety Agents / therapeutic use
  • Anxiety / drug therapy
  • Child
  • Child, Preschool
  • Drug Combinations
  • Emergency Treatment
  • Female
  • Fentanyl / adverse effects
  • Fentanyl / therapeutic use*
  • Fractures, Bone / therapy
  • Humans
  • Joint Dislocations / therapy
  • Ketamine / adverse effects
  • Ketamine / therapeutic use*
  • Male
  • Midazolam / therapeutic use
  • Pain / drug therapy*
  • Respiration / drug effects
  • Treatment Outcome


  • Analgesics, Opioid
  • Anesthetics, Dissociative
  • Anti-Anxiety Agents
  • Drug Combinations
  • Ketamine
  • Midazolam
  • Fentanyl