Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation

WITHDRAWN: Interventions for treating wrist fractures in children

BACKGROUND

Approximately a third of all fractures in children occur at the wrist, usually from falling onto an outstretched hand.

OBJECTIVES

We aimed to evaluate removable splintage versus plaster casts (requiring removal by a specialist) for undisplaced compression (buckle) fractures; cast length and position; and the role of surgical fixation for displaced wrist fractures in children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 4), MEDLINE (from 1966), EMBASE (from 1988), CINAHL (from 1982) and reference lists of articles. Date of last search October 2007.

SELECTION CRITERIA

Any randomised or quasi-randomised controlled trials comparing types and position of casts and the use of surgical fixation for distal radius fractures in children.

DATA COLLECTION AND ANALYSIS

Two authors performed trial selection. All three authors independently assessed methodological quality and extracted data.

MAIN RESULTS

The 10 included trials, involving 827 children, were of variable quality.Four trials compared removable splintage versus the traditional below-elbow cast in children with buckle fractures. There was no short-term deformity recorded in all four trials and, in one trial, no refracture at six months. The Futura splint was cheaper to use; a removable plaster splint was less restrictive to wear enabling more children to bathe and participate in other activities, and the option preferred by children and parents; the soft bandage was more comfortable, convenient and less painful to wear; home-removable plaster casts removed by parents did not result in significant differences in outcome but were strongly favoured by parents.Two trials found below-elbow versus above-elbow casts did not increase redisplacement of reduced fractures or cast-related complications, were less restrictive during use and avoided elbow stiffness.One trial evaluating the effect of arm position in above-elbow casts found no effect on deformity.Three trials found that percutaneous wiring significantly reduced redisplacement and remanipulation but one of these found no advantage in function at three months.

AUTHORS' CONCLUSIONS

Limited evidence supports the use of removable splintage for buckle fractures and challenges the traditional use of above-elbow casts after reduction of displaced fractures. Although percutaneous wire fixation prevents redisplacement, the effects on longer term outcomes including function are not established.Further research is warranted on the optimum approach, including splintage, for buckle fractures; and on the use of below-elbow casts and indications for surgery for displaced wrist fractures in children.

Case-series of nurse-administered nitrous oxide for urinary catheterization in children

BACKGROUND

Children undergoing urologic imaging studies requiring urethral catheterization experience considerable discomfort and psychological distress. Nitrous oxide sedation may mitigate these detriments but the requirement for physician administration has limited the applicability of this technique.

METHODS

Registered nurses underwent the nitrous oxide training requirements prescribed for state licensure of dentists and dental hygienists, with special emphasis on pediatric sedation principles. To evaluate the safety of nurse-administered nitrous oxide, we consecutively enrolled all children (ASA PS I-II) sedated for urethral catheterization for urologic imaging in an observational trial designed to identify sedation-related adverse events.

RESULTS

Nitrous oxide was administered on 1018 occasions. There were no major adverse events (apnea, oxygen saturation <92%). Minor adverse events (diaphoresis, nausea, vomiting) occurred in 4% of patients. Eight patients (1%) were described as over-sedated. In 11 (1%) patients, nitrous oxide provided insufficient sedation for completion of urologic imaging.

CONCLUSIONS

Nitrous oxide sedation can be provided by a nurse-administered program in pediatric radiology. Administration of nitrous oxide for pediatric procedures by adequately trained nursing staff with appropriate multidisciplinary oversight may increase children's access to this sedative/analgesic drug.

Nitrous oxide in emergency medicine

Safe and predictable analgesia is required for the potentially painful or uncomfortable procedures often undertaken in an emergency department. The characteristics of an ideal analgesic agent are safety, predictability, non-invasive delivery, freedom from side effects, simplicity of use, and a rapid onset and offset. Newer approaches have threatened the widespread use of nitrous oxide, but despite its long history this simple gas still has much to offer. "I am sure the air in heaven must be this wonder-working gas of delight". Robert Southey, Poet (1774 to 1843)

A comparison of prilocaine and lidocaine for intravenous regional anaesthesia for forearm fracture reduction in children

BACKGROUND

In this prospective blinded randomized study, we compared prilocaine and lidocaine for intravenous regional anaesthesia for forearm fracture reduction in children.

METHODS

Two hundred and seventy-nine children, aged 316 years, were enrolled and randomly assigned to receive 3 mg.kg-1 of either prilocaine or lidocaine. The severity of fracture was classified according to the displacement of the radius (i.e., no radial fracture, angulated, partly displaced or completely displaced). Pain during the procedure was assessed as none, minimal, moderate or severe.

RESULTS

There was no significant difference between agents in the proportion of patients with a successful reduction (prilocaine 94%, lidocaine 92%). Compared with less severe fractures, successful reduction was less common in the completely displaced fractures (P < 0.001) but there was no significant difference in this category between anaesthetic agents (successful reduction: prilocaine, 84%; lidocaine, 78%). Analgesia was superior in the lidocaine group with more patients having no or minimal pain (prilocaine, 78%; lidocaine, 90%, P < 0.05).

CONCLUSIONS

Both agents are effective for forearm fracture reduction in children with a high incidence of successful reductions, particularly in the minimally or nondisplaced fractures. Lidocaine provided superior analgesia.