Pediatric Analgesia and Sedation for Painful Procedures Lou E. Romig MD, FAAP, FACEP Miami Children’s Hospital Emergency Medicine www.jumpstarttriage.com

In the ED, Sedation &Analgesia beats the heck out of S&M! A.K.A… In the ED, Sedation &Analgesia beats the heck out of S&M!

This kind of S&M… Punctured eardrums! Hysterical parents! Kicks and bites in the …! Hypersonic screams!

Why talk about these things at an EMS conference?

Sedation & Analgesia and EMS We’re all on the same team. Knowing what may happen in the ED can help in patient and family management. Relieving pain should be considered an EMS task.

Sedation & Analgesia and EMS Some of the drugs used for S&A are also used in the field. Many EMS providers also work in an Emergency Department or Outpatient care setting.

If this were your child…?

Objectives: State the differences between sedation, anesthesia, and analgesia. Discuss the physiological and psychological effects of pain and anxiety in children. Name 2 sedatives, 2 analgesics and 1 anesthetic commonly used for pediatric outpatient procedures.

Objectives: List the most commonly used routes to deliver sedation and analgesia for children, as well as examples of medications used by each route. Review the potential complications of conscious sedation and parenteral analgesia in children and recommended monitoring procedures.

Sedation A medically induced state of depressed level of consciousness Used to facilitate the smooth and uninterrupted performance of a procedure Used to reduce patient anxiety and improve cooperation

Sedation Usually done at level of conscious sedation Protective airway reflexes are preserved Maintains own airway Appropriate response to verbal command or stimulation

Sedation Rarely done at level of deep sedation Protective airway reflexes may be compromised May require assistance maintaining airway No purposeful response to verbal command or painful stimulus

Sedation is a balancing act

Uses for Sedation Diagnostic studies CT/MRI Lumbar puncture Joint tap

Uses for Sedation Therapeutic interventions Wound management Fracture/dislocation reduction and immobilization Incision and drainage Dental procedures

Anesthesia General: Local/regional: Medically induced state of unconsciousness accompanied by amnesia and analgesia Local/regional: Procedure resulting in the blocking of pain sensation by direct action upon the sensory nerves

Indications for Anesthesia: Inability to provide adequate analgesia due to intensity or nature of pain during procedure May be used in conjunction with sedation and/or analgesia

Indications for Anesthesia Local and regional anesthetic blocks are commonly used for wound care, orthopedic, and dental procedures. Local or regional blocks are occasionally used for longer duration outpatient pain management.

the relief or prevention of pain. Analgesia Medical treatment for the relief or prevention of pain.

Analgesia Indication: Contraindications: PAIN Inability to tolerate analgesic agents Procedure requires that patient be able to indicate when he/she feels pain

Note that youth is not a contraindication for pain management!

Why treat pain and anxiety in children?

Psychological Effects Pain and anxiety can be traumatic psychological experiences. Fear of and lack of trust for medical personnel and other caregivers Fear, anxiety and guilt among family members

Physiological Effects Release of catecholamines Elevated heart rate Elevated blood pressure Elevated respiratory rate Increased oxygen demand

Physiological Effects Vagal stimulation Fainting Low heart rate Low blood pressure Breath holding

Pain and anxiety Healthy children can tolerate the physiologic effects well. Frail children may not tolerate the altered physiology well but are also at higher risk of complications, more from sedation than from analgesia.

The body remembers…

“In vulnerable prematurely born infants, repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior.” Grunau R. Early pain in preterm infants. A model of long-term effects. Clin Perinatol. 2002 Sep;29(3):373-94, vii-viii.

Sedation Anesthesia Analgesia ?

Choosing an Intervention Is the patient already in pain? Analgesia Will the procedure cause pain? Anesthesia

Choosing an Intervention Is the patient anxious or likely to be anxious during the procedure (even with pain management)? Patient movement Need for cooperation Physiologic effects of anxiety may interfere with procedure Psychological trauma Behavioral intervention Sedation

Anesthesia

Indications for use: Inability to provide adequate analgesia due to intensity or nature of pain during procedure May be used in conjunction with sedation and/or analgesia

“Caine” anesthetics Lidocaine most commonly used Applied locally by injection at the injured area Applied by injection at nerve sites to block pain in regions Applied intravenously to provide anesthesia in an area of intentionally restricted circulation

“Caine” anesthetics Duration of anesthesia depends upon agent used Lidocaine works for 30-60 minutes Must ask about potential allergies to all anesthetic agents incorporating the “caine” suffix

“Caine” anesthetics Toxicity: Dizziness, drowsiness Agitation, confusion, hearing loss Seizures, coma Bradycardia, hypotension

Sedation

Indications for sedation Need to facilitate cooperation Need for a complicated or extended procedure Desire for amnesia Relief of muscle spasm

Sedatives Chloral hydrate Oral or rectal administration 30-45 minutes before onset of action Long period of sedation, length variable Not suited for emergency outpatient ortho procedures

Sedatives Demerol, Phenergan, Thorazine (DPT) No longer in common use Intramuscular administration Long time to offset Phenergan and thorazine can cause extrapyramidal reactions Demerol can cause nausea, vomiting

Sedatives Benzodiazepines Diazepam, midazolam most commonly used PO, PR, IM, IV, nasal (midazolam) Time to effect depends on route of administration Diazepam works well for muscle spasms Midazolam has excellent amnestic effects

Sedatives Ketamine Most effective when used IV May induce post-emergence agitation Often used in combination with benzodiazepines Rapid onset, variable offset Excellent sedation, amnesia and analgesia

Sedatives Barbiturates Nembutal most commonly used PO, PR, IV Onset of action dependent upon route of administration (several minutes to up to an hour) Depressive effects potentiated by concomitant use of benzodiazepines

Complications Sedatives do NOT necessarily provide analgesia Vomiting, aspiration Respiratory depression Circulatory depression

Precautions Assess risks due to acute or chronic illnesses Assess NPO status Assess ability to manage a compromised airway Provide constant physiologic monitoring Perform only in a setting where immediate advanced life support interventions are available

Analgesics

In general, pain is under-treated in children.

Indications for Analgesia PAIN at any age!

Don’t Forget! Proper immobilization, positioning and application of ice can be very effective in treating and even preventing pain.

Analgesics Non-narcotic Acetaminophen PO, PR Ibuprofen PO Ketoralac PO, IM, IV No difference demonstrated in effectiveness between ibuprofen and ketoralac

Analgesics Narcotics Morphine IM, IV Demerol IM, IV Fentanyl IV, PO Codeine and analogs PO Morphine and demerol may cause nausea, vomiting, and histamine release

Analgesics Nitrous oxide Rapid onset and offset of analgesia Requires special equipment for administration Requires cooperative patient Does not work well for reduction of acute, sharp pain such as that of fracture reduction

Complications of Analgesia Respiratory depression with parenteral administration Sedation Nausea, vomiting Constipation (codeine) Unintentional overdose Addiction is not a consideration

Risks Benefits

Risks To Patient Potential complications due to medications used Potential psychological and physiological complications due to pain and anxiety Potential for sub optimal outcome of procedure due to poor patient cooperation

Risks to Medical Caregivers Responsibility for assessing and managing all potential complications Alienation of child and family against medical caregivers Professional satisfaction Personal impact

Benefits to Patients Reduction or elimination of pain and anxiety Maintaining trust and confidence in medical caregivers Helping family caregivers to better deal with the child’s trauma

Benefits to Medical Caregivers Improved interactions with children and their families Better professional performance Greater personal satisfaction and gratification Less fear of treating children

Take Home Lessons There is no excuse for giving inadequate analgesia to children. Sedation may be indicated for the benefit of the child, the family, and the caregivers but must be done with careful consideration of the risks.

The End. Thank You!