AOTW: Hematoma Blocks
Posted on: August 19, 2014, by : Katie Donnelly MD
Title: Evaluating the Hematoma Block as an Adjunct to Procedural Sedation for Closed Reduction of Distal Forearm Fractures
Methods: Randomized control trial of lidocaine vs normal saline injections for hematoma blocks in children that were going to be sedated for forearm fractures already. 90 total patients (50 received lido, 40 NS). Children were a convenience sample pulled from Hasbro Children’s Hospital from November 2005 to September 2008. Patients were excluded if they had a complex fracture (open, neurovascular damage) or sensitivity to lidocaine. All children received a standard starting dose of ketamine (0.75 mg/kg) and midazolam (0.05mg/kg) and then once sedated, had hematoma block placed. Providers were allowed to give additional standardized doses of ketamine and midazolam as needed for perceived patient distress. The patient, ED provider, orthopedist and bedside nurse were all blinded to type of hematoma block administered. The reductions were videotaped and scored using the Observational Score of Behavioral Distress-Revised (OSBD-R).
Results: Patients in both classes received about 1 mg/kg of ketamine and 0.05 mg/kg midazolam. No significant difference was found between amount of medications given, pain scores or time to recovery.
Discussion: I’m not sure how helpful this study is to us. It’s a small N (we probably do 90 reductions in 1-2 months here!), and the researchers were trying to find pretty small changes, given then behavioral distress scores were pretty low to begin with and that ketamine is a drug that most children recover from pretty quickly. Also, it is not typically our practice to give children midazolam for reductions. The more interesting question would be can we avoid the use of ketamine and midazolam all together. A brief literature search did not show any studies that looked at only hematoma blocks in children, just in combination with other drugs.
So, no easy answers for us.
comments so far:
Dave Mathison:
I think a better study would be to have one study arm be a reduced minimum ketamine dose (1 mg/kg) with lidocaine and have the other be a greater minimum ketamine dose (1.5-2) without lidocaine and look at time to recovery, vomiting, and a clinical outcome. Arguing that lidocaine as an adjunct to a lesser sedation will produce decreased LOS.
Jennifer Chapman:
Agreed! The biggest value would be to avoid the sedation. But this study was trying to show a lowered need for meds with the block. Some institutions do Bier blocks, which would obviate the need for any sedation. This is done more overseas from what I see on the listserve.