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

2. 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!

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

4. Why talk about these things at an EMS conference?

5. 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.

6. 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.

7. If this were your child…?

8. 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.

9. 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.

10. 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

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

12. 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

13. Sedation is a balancing act

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

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

16. 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

17. 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

18. 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.

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

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

21. Note that youth is not a contraindication for pain management!

22. Why treat pain and anxiety in children?

23. 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

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

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

26. 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.

27. The body remembers…

28. “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 Sep;29(3):373-94, vii-viii.

29. Sedation
Anesthesia
Analgesia ?

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

31. 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

32. Anesthesia

33. 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

34. “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

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

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

37. Sedation

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

39. 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

40. 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

41. 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

42. 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

43. 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

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

45. 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

46. Analgesics

47. In general, pain is under-treated in children.

48. Indications for Analgesia
PAIN at any age!

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

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

51. 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

52. 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

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

54. Risks
Benefits

55. 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

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

57. 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

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

60. 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.

61. The End.
Thank You!