Managing Pediatric Pain & anxiety in the ER A case-based review Have any of you ever had a bad experience as a child, in the medical setting? Do you think it affects how to seek care today? Does it influence how you seek care for your own children?

Anything to declare? Nope.

CASE#1: The cookie MONSTER On his way to pillage the cookie jar, 5 yr old Jake fell off a chair, hitting his forehead on the kitchen counter. No known LOC. Lots of blood and tears but he is happy now. He even ate two cookies in the waiting room.

The laceration What now?

While watching this 3 minute video, please note what you think was done well. Please also note anything you would have done differently. play from 10:45 to 13:30

CASE #2: the sick neonate 17 day old baby girl Amber presents to the ER with a fever. She is not feeding well and her RR is 70. While in ER, she has a witnessed 1 minute-long seizure.

How will you manage her pain? procedures NEEDED options Blood test IV or IO LP Breastfeeding, parental presence Warm environment Sucrose Topicals

CASE#3: the hairy eyeball Arthur is 6 yrs old. He woke up this morning with his left eye swollen shut and a fever. It hurts him to move his eye around, and he really does not feel well at all. Arthur hates needles. He hates doctors. He had a really bad experience once before in your ER.

Needle phobia Usually develops between ages 4-6 yrs Potential long term impact stress on patient and caretakers (parents and health care providers) reduced vaccination rates? future avoidance of medical care TEDx: Pain, empathy and public health: Dr Amy Baxter

What we want to avoid… and how? play all of it (3 1/2 min)

IV ACCESS tricks Age-appropriate distraction (iPad, games, movies, jokes, music, singing) Age-appropriate explanations Give choices whenever possible Hypnosis? Topicals: EMLA, liposomal lidocaine, Buzzy device, Vapocoolant spray Children < 3/12 old Oral Sucrose +/- pacifier D25(diluted D50), 2mL on anterior tongue Breastfeeding, warm environment

CASE#4: The Casperflip* *A trick in which the board is flipped for half a kickflip, then caught upside down and flipped back over and spun backside 180 degrees on its vertical axis, all while in the air. CASE#4: The Casperflip* 12 yr old Matt spends every weekend practicing his jumps at the Skate Board park. Today he tried a new, gnarly trick. Sadly, he bailed. His right hand feels tingly, and he is in a lot of pain. (ouch)

Use a checklist to prepare for the procedure. Deep sedation Use a checklist to prepare for the procedure. ketamine propofol 1-2 mg/kg IV over 30-60 sec, repeat half dose prn 4-5 mg/kg IM, redosing can be tricky AVOID: age < 3 months, schizophrenia, or if hypertension/ tachycardia is a concern CAUTION: increased risk of laryngospasm Preferred for longer procedures SIDE-EFFECTS: emergence distress (treat with midazolam) post-procedure emesis (consider prophylactic ondansetron) 0.5-1 mg/kg IV, then 0.5 mg/ kg q1-2 min prn AVOID: avoid if hypotension is a concern Preferred for shorter procedures and where muscle relaxation is of benefit; ACEP’s procedural sedation clinical policy stipulates “Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.” (2014)

For quick drug/dosage reference, check out the App Pedi STAT

REFERENCES TEDx: Pain, empathy and public health: Dr Amy Baxter Emergency Medicine Cases, Episode 67: Pediatric Pain Management (2015) Emergency Medicine Cases, Episode 76: Pediatric Procedural Sedation (2016) Strayer, Ruben, EM Updates: PSA Checklist (2013)