The provision of effective analgesia in children presenting with injuries in the emergency department presents as a challenge, with pain control efforts often proving inadequate. Intranasal administration of pain medications provides rapid analgesia with minimal discomfort. Ketamine, a dissociative anesthetic, is commonly used in facilitating painful procedures in the emergent pediatric setting. In this study, the Pain Reduction with Intranasal Medications for Extremity Injuries (PRIME) trial, 90 children were randomized to receive intranasal ketamine (1.5 mg/kg) or intranasal fentanyl (2 ug/kg) to determine whether intranasal subdissociative ketamine is noninferior to intranasal fentanyl for the treatment of acute pain associated with traumatic limb injuries in children presenting to the emergency department without routinely administered ibuprofen/acetaminophen. Researchers found that 30 minutes after medication administration, the mean visual analog scale reduction was 30.6 mm (95% CI 25.4 mm to 35.8 mm) for children that received ketamine, and 31.9 mm (95% CI 26.6 mm to 37.2 mm) in the fentanyl group. Pain reduction was sustained over the first 60 minutes for both groups. Ketamine was noninferior to fentanyl in terms of pain reduction 30 minutes after study medication administration. There was no significant difference in highest achieved sedation scores between the groups. Of note, the risk of adverse events was higher in the ketamine group (RR 2.5, 95% CI 1.5 to 4.0), however, all events were minor and transient. The use of rescue analgesia was similar between groups. This study therefore shows that the use of intranasal ketamine may be used in achieving effective analgesia that is noninferior to fentanyl in children with acute extremity injuries.
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