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Use of Combined Transmucosal Fentanyl, Nitrous Oxide, and Hematoma Block for Fracture Reduction in a Pediatric Emergency Department

Jiménez, Ana MD; Blázquez, Daniel MD; Cruz, Jaime MD; Palacios, Alba MD; Ordóñez, Olga MD; Marín, Milagros PhD; Ruíz-Contreras, Jesús PhD

doi: 10.1097/PEC.0b013e31825d20f6
Original Articles

Objective The objective of this study was to evaluate the use of combined inhaled nitrous oxide (NO), hematoma block (HB), and transmucosal fentanyl (TMF) as sedoanalgesia in the reduction of radioulnar fractures in children in a pediatric emergency department (PED).

Methods A retrospective, analytical observational study examining the cases of radioulnar fracture reduction in PED from 2007 to 2009 in children from 4 to 15 years old. The cases were divided into 2 groups: those in which only NO + HB was used and those in which TMF was combined with NO + HB. The pain perceived by the child, the doctor, and the nurse was studied during the procedure with 0- to 10-point scales (10 being severe pain). Satisfaction of the medical professionals, duration of the procedure, and the adverse effects that appeared were also studied.

Results Eighty-one children were included. Sixty-four children (79%) received NO + TMF + HB, and 17 children (21%) received NO + HB only. The pain perceived by the child during the procedure in the group receiving NO + TMF + HB was 2.5 (95% confidence interval [CI], 1.8–3.1) compared with 3.9 (95% CI, 2.3–5.5) in the NO + HB group (P = 0.035), the pain perceived by the doctor was 2.6 (95% CI, 2–3.2) compared with 4 (95% CI, 1.6–4), and by the nurse was 2.7 (95% CI, 2–3.3) compared with 3.9 (95% CI, 2.3–5.5), respectively. Adverse events appeared in 15.3% of the NO + TMF + HB group and in 40% of the NO + HB group.

Conclusions The association of NO + TMF + HB in the reduction of radioulnar fractures in PED improves pain control compared with the NO + HB combination. New studies are required to confirm the benefit and safety of this drug combination.

From the Department of Pediatrics, Hospital Universitario 12 de Octubre, Madrid, Spain.

Disclosure: The authors declare no conflict of interest.

Reprints: Daniel Blázquez, MD, Department of Pediatrics, Hospital Universitario 12 de Octubre, Avda de Córdoba sn, 28041, Madrid, Spain (e-mail:

A.J. and D.B. contributed equally to this work.

© 2012 Lippincott Williams & Wilkins, Inc.