Perform procedural sedation for a fracture reduction — OSCE

Candidate brief

You have this station to assess a 5-year-old before procedural sedation for an urgent forearm fracture reduction, perform the structured pre-sedation safety check, choose and dose the agent, set up the monitoring and rescue equipment, outline the conduct and the management of a deterioration, and discuss the recovery and discharge criteria. Treat this as a time-critical but controlled procedure in a child who meets the criteria for sedation by a trained team. [1] [2]

Key teaching and management objectives

Begin with the structured pre-sedation assessment. Confirm the child is ASA I (previously well, no severe systemic disease), which makes him suitable for procedural sedation by a trained team. Take the history: weight in kilograms for dosing, the procedure and its anticipated pain, the fasting history (light meal three hours ago), recent upper airway infection or wheeze, snoring, reflux, previous sedation problems and allergies. Perform a focused airway assessment — mouth opening, neck movement, mandibular recession, tonsils, no stridor — and record baseline observations. Document consent with the parent. [1]

Use the fasting history to inform risk, not to delay the procedure. The evidence shows aspiration during emergency procedural sedation is negligible and is not predicted by fasting status; aspiration is prevented by sedation depth and airway care. Fasting is not a substitute for monitoring, and the elective anaesthesia fasting intervals should not gate a child in pain. Proceed with sedation now. [4]

Prepare the team, equipment and monitoring before any drug. Confirm a two-person team (one to sedate and observe the airway, one to perform the reduction). Place rescue airway equipment at the bedside: suction, a bag-valve-mask, age-appropriate oropharyngeal and nasopharyngeal airways, and oxygen. Attach continuous monitoring — pulse oximetry, heart rate, and capnography — and record a baseline. Secure intravenous access. Perform a two-person weight and dose check. [1] [3]

Choose and dose the agent. For a painful procedure needing stillness in an ASA I child, dissociative ketamine is appropriate: 1 to 1.5 milligrams per kilogram intravenously over 30 to 60 seconds, with onset within 30 to 60 seconds and a clinical duration of 10 to 20 minutes. State that ketamine preserves airway reflexes and sympathetic tone and provides analgesia, that vomiting occurs in roughly 10 to 15 percent, that emergence phenomena may occur, and that it is relatively contraindicated in infancy, raised intracranial pressure and active upper airway infection. [2]

During the procedure, maintain continuous monitoring and a dedicated observer. Be ready to manage deterioration: for transient hypoxia or apnoea, stimulate, open the airway, give 100 percent oxygen by bag-valve-mask and withhold further sedation; for laryngospasm (stridor, paradoxical movement, falling saturation), clear secretions and apply sustained positive airway pressure with 100 percent oxygen, with suxamethonium (1 to 1.5 milligrams per kilogram intravenously) if it does not break. If an opioid or benzodiazepine were implicated, naloxone 0.1 milligram per kilogram (maximum 2 milligrams) or flumazenil 0.01 milligram per kilogram (maximum 0.2 milligrams first dose) is the reversal agent — with the caveat that the sedative outlasts the reversal. [2] [1]

Close with recovery and discharge. Recover in a monitored area with continuous pulse oximetry and an observer. Recovery after ketamine takes roughly 60 to 120 minutes. Assess the modified Aldrete score (activity, respiration, circulation, consciousness, oxygen saturation); a score of 9 or above, sustained, supports discharge. The child should be alert or at baseline, with a patent airway, adequate breathing, stable observations and tolerance of oral intake. Give the family aftercare advice: supervision by a responsible adult, no driving or cycling, and return precautions for drowsiness, breathing problems or vomiting. [1]

Marking domains

• Pre-sedation assessment and patient safety (4 marks). Correctly assigns ASA I; takes a structured history including weight, procedure, fasting, airway symptoms and allergies; performs a focused airway assessment; documents consent; confirms a two-person team and rescue equipment.
• Fasting decision (2 marks). States that fasting informs risk but does not delay a time-critical sedation, citing the negligible aspiration risk and that fasting is not a substitute for monitoring.
• Agent choice and dosing (3 marks). Chooses ketamine with the correct intravenous dose (1 to 1.5 milligrams per kilogram over 30 to 60 seconds), names onset and duration, and states the contraindications and adverse effects.
• Monitoring and management of deterioration (3 marks). Names continuous pulse oximetry, heart rate and capnography with a dedicated observer; describes the stepwise management of laryngospasm and the reversal-agent doses with the re-sedation caveat.
• Recovery and discharge (2 marks). Names the modified Aldrete score and the discharge criteria, the recovery time for ketamine, and the aftercare advice. [1] [3]