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I've actually witnessed a number of cases of paradoxical excitation after oral midazolam use.  It's usually children 2-5 years old, more often males, who usually are quite anxious before administation.  I will warn that parents that this may happen, but interestingly enough, the amnestic properties don't seem to be affected even if the child is hysterical.  I've found with preparatory explanation, most parents tolerate this without any real difficulties

Lisa Amir, MD, MPH
Unit of Emergency Medicine
Schneider Children's Medical Center of Israel

-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]]On Behalf Of Ralph W. Kelly, DO,
FACEP, FAAP
Sent: Monday, February 11, 2008 11:48 PM
To: [log in to unmask]
Subject: Re: ketamine for LP in ER


 
 
I have witnessed the paradoxical excitation after intra-nasal Versed I  gave 
for sedation several years ago. It was basically 45-60 minutes of a  maniacal 
3 yo. No one including the parents could calm him. It took a lot  of 1:1 
reassurance, but the parents were surprisingly understanding. I  have not used it 
intra-nasally since then. I still use it IV when appropriate.  It breaks your 
heart to see the patient worse after you treat them.
 
It was quite similar to an episode I experienced with my own daughter a  long 
time ago when I was a pediatric resident and she was quite young (about 1.5  
yrs old). I gave her Benadryl so she would sleep on a flight from San Diego  
to Dallas. She acted as if she might be possessed soon after take-off, and did  
everything but destroy the airplane. I felt like I was in a Twilight Zone 
movie,  and the other passengers thought so, too. Nothing worked to calm her, but 
she  was fine 3 hours later for the Grandparents. Antihistamines never 
touched her  lips or many of my young patient's lips after that.
 
Ralph W.  Kelly, DO, CPE, FACEP, FAAP, FAIHQ
Emergency Department Medical Director and  Chairman
Trinity Medical Center
RHD Memorial Medical  Center



In a message dated 2/11/2008 3:12:52 P.M. Central Standard Time,  
[log in to unmask] writes:

I have  reviewed the available literature on ketamine.  I have never read nor 
 
witnessed paradoxical excitation nor decreased respiratory efforts after  
it's use.;  Does anyone have a reference for these  assertions?

Wm Gibson MD, FACEP
----- Original Message -----  
From: "Dr Saeed Alobeidani" <[log in to unmask]>
To:  <[log in to unmask]>
Sent: Monday, February 11, 2008 5:18  AM
Subject: Re: ketamine for LP in ER


> Thanks to  all,
> Medazolam is good to keep child sedated but there is the risk of  
> paradoxical
> excitation and decrease respiratory efforts after  procedure.
>
> ketamine has analgesic  and amnesic  effect.
> Having no problem with doing the procedure doesn't mean the  child and
> parents are satisfied about it.
> We had instance of  parents refusing to continue the procedure because of
> child's  continous crying.
> ketamine will be the drug of choice to  keep  everybody happy.
>
> In Advanced PEM conference in NY last year  there was a talk that argued
> about the scientific basis of not using  ketamine for head injury pt.
>
>
> Saeed Alobeidani
>  Royal hospital
>
> For more information, send mail to  [log in to unmask] with the 
> message: info PED-EM-L
>  The URL for the PED-EM-L Web Page is:
>   http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
>  

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