Original Contribution Comparison of ketamine–low-dose midozolam with midazolam-fentanyl for orthopedic emergencies: a double-blind randomized trial ☆ Erdem Cevik MD ⁎ , Serkan Bilgic MD, Erden Kilic MD, Orhan Cinar MD, Hakan Hasman MD, Ayhan Yahya Acar MD, Murat Eroglu MD Department of Emergency Medicine, Gulhane Military Medical Academy, GATA Acil Tip Anabilim Dalı, Etlik, Ankara 06010, Turkey Received 16 May 2012; revised 31 May 2012; accepted 1 June 2012 Abstract Objective: Most of the fractures and dislocations are reduced in the emergency setting. Many drugs are available for procedural sedation and analgesia in the emergency department (ED); however, the adverse effects are still a common problem. The aim of our study was to compare the 2 drug combinations. Method: We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED after a traumatic event and required urgent reduction either for a fracture or dislocation. Patients were randomized to midazolam-fentanyl (MF) group or ketamine–low-dose midazolam (KM) group. Hypoxia, duration of hypoxia, need for oxygen, time to onset of sedation, recovery time, pain scores during reduction, and sedation depth were set as primary outcome measures and were recorded. Results: A total of 498 patients who presented to ED with extremity injury and required closed reduction were assessed; 130 of them were approached for eligibility and 69 patients were excluded. The remaining 61 patients were randomized to either KM group (n = 31) or MF group (n = 30). Hypoxia and duration of hypoxia were significantly lower in the KM group compared with the MF group. Patients in the KM group reported significantly lower pain scores during reduction; however, adverse effects were higher compared with MF group. Conclusion: Both drug combinations can be effectively used for procedural sedation and analgesia; however, with lower risk for hypoxia and lower pain scores, KM combination stands as a reasonable choice for orthopedic interventions in the emergency unit. © 2013 Elsevier Inc. All rights reserved. 1. Introduction Trauma is one of the most common causes of referral to the emergency department (ED). Most of the fractures and dislocations are reduced in the emergency setting. These procedures can be distressing and painful for the patient. Alleviating pain and anxiety, especially in pediatric patients, is a specific issue that the emergency physician usually confronts [1]. ☆ Funding and support: Nothing to declare. ⁎ Corresponding author. Tel.: +90 312 304 3015. E-mail addresses: cevikerdem@yahoo.com (E. Cevik), serbil11@gmail.com.tr (S. Bilgic), erdenkilic@gmail.com.tr (E. Kilic), orhancinar@yahoo.com (O. Cinar), hakan_has@yahoo.com (H. Hasman), yahya_acar@yahoo.com (A.Y. Acar), drmeroglu@yahoo.com (M. Eroglu). www.elsevier.com/locate/ajem 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2012.06.012 American Journal of Emergency Medicine (2013) 31, 108–113