Intranasal Fentanyl and Inhaled Nitrous Oxide for Pediatric Fracture Reduction

Authors: Hoeffe J et al., Am J Emerg Med 2017 Jan 5;

Combination intranasal fentanyl and nitrous oxide provided adequate pain control for children undergoing reduction of mildly to moderately displaced fractures and dislocations.

In a prospective, observational study conducted at two children’s hospitals in Canada and Australia, investigators evaluated the efficacy and safety of intranasal fentanyl plus nitrous oxide (N₂O) for children (age range, 4–18 years) undergoing procedural sedation for reduction of fractures and dislocations. Children with mildly or moderately displaced fractures of the forearm, fractures of the wrist or hand, dislocation of a finger or patella, or displaced femur fractures requiring application of traction were included. Patients received intranasal fentanyl (1.5 µg/kg; 100 µg maximum), with additional doses (0.5 µg/kg) at the discretion of the treating physician. N₂O was self-administered by breathing through the mask as a fixed 50%:50% N₂O:O₂ mixture or as a variable 0% to 70% mixture.

Of 90 children (mean age, 10 years) enrolled over 1 year, most had mild pain prior to the procedure, and there was no difference in patient pain scores before and during the procedure (excluding 17 patients who did not remember the procedure). However, research assistant perception of patient pain level was higher during the procedure than before. There were no serious adverse events. Vomiting occurred in 12% of patients; 30% of patients receiving a 70%:30% mixture experienced vomiting compared with 11% of those receiving a 50%:50% mixture. The median rating of satisfaction with the procedure was “very satisfied” for patients, parents, and staff; 89% of patients and 96% of physicians reported they would use the same sedation again.

Comment

Intranasal fentanyl plus inhaled nitrous oxide (where available) is a great option for reduction of mildly to moderately displaced pediatric fractures and dislocations, particularly when intravenous access is difficult to obtain or otherwise unnecessary. Providers may also consider pretreatment with oral ondansetron prior to sedation, particularly when higher percentages of N₂O are used.