This week’s case highlights the challenging aspects of a complete physical exam on irritable patients and how to best complete urgent sedation. We discussed various routes (IM, IN, IV) as well as the risks and benefits of different sedatives based on the indication.

The patient was sedated with IM ketamine with IV access obtained during sedation. Sats and end tidal were normal on room air while sedated. CT chest showed extensive pneumomediastinum and pneumopericardium. Pediatric surgery recommended obtaining esophagram with fluoroscopy to evaluate for esophageal perforation which was negative. The patient was discharged home and has not returned to the ED. 

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