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Procedural Sedation and Analgesia in the Emergency Department. Itai Shavit, MD. 1. Unfortunately, this is usually not what we see in the ED …. Pain and suffering go together. Acute Pediatric Pain. Children may experience severe pain. What if this was your child ?.

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Procedural Sedation and Analgesia

in the Emergency Department

Itai Shavit, MD

1





Children may experience severe pain

Children may experience severe pain

What if this was your child ?


Do we really need to treat pediatric pain in the ed ethics
Do we really need to treat Pediatric pain in the ED?(Ethics?)

There is no ethical justification to withhold analgesia when a child is clearly in pain



מדינת ישראל - משרד הבריאות החטיבה לענייני בריאות

13במאי 2003

מינהל רפואה

הנדון: סדציה בילדים על ידי רופא שאינו מרדים

"... על כל מטפל חלה החובה למזער את הכאב והפגיעה בילדים בכל האמצעים העומדים לרשותו...."


Pain is an Emergency לענייני בריאות

Relieving pain & anxiety

are an ED task!!

(today’s standard of care)


We have all experienced pain
We have all experienced pain … לענייני בריאות

PAIN ASSESSMENT


Inability to verbalize pain appropriately under 2 years of age. At age 3-7 most children are competent to provide accurate information (using assessment tools)

Behavioral pain measures are more useful than physiological parameters. Physiologic parameters are unreliable


Anxiety decreases pain threshold age. At age 3-7 most children are competent to provide accurate information (using assessment tools)

(Fear makes every pain greater)


Types of pain: age. At age 3-7 most children are competent to provide accurate information (using assessment tools)

Pain on presentation -Due to injury -Due to illness

Procedure-related pain (the pain we create)


Pain on presentation age. At age 3-7 most children are competent to provide accurate information (using assessment tools)

Due to injury

Fractures, Burns, Amputations

Severe pain

Severe pain

Severe pain

Due to illness

Severe pain

Severe pain

Peritonitis, Sickle cell crisis, Otitis Media, Migraine


Severe pain should be treated age. At age 3-7 most children are competent to provide accurate information (using assessment tools)ASAP


Morphine? age. At age 3-7 most children are competent to provide accurate information (using assessment tools)


Procedure-related pain age. At age 3-7 most children are competent to provide accurate information (using assessment tools)

The pain we create!

Fracture reduction, Lacerations repair,

Urine Cathetherization , Spinal tap,

Arthrocentesis, IVs


Procedure-related pain may be age. At age 3-7 most children are competent to provide accurate information (using assessment tools)

sometimes painful

but

it is always stressful


Children younger than 8 years are not able to understand that short term pain may have long term benefit


קורס סדציה that short term pain may have long term benefit (מ.ס.ר, תל השומר)

Procedural Sedation and Analgesia (PSA)

American College of Emergency Physicians, 1998

“A Technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia is intended to result in a depressed level of consciousness but one that allows the patient to maintain airway control independently and continuously. Specifically, the drugs, doses, and techniques used are not likely to produce a loss of protective airway reflexes”.


קורס סדציה that short term pain may have long term benefit (מ.ס.ר, תל השומר)

Safe environmentresuscitation space, resuscitation equipment

Trained PersonnelPALS & Pediatric sedation course trained, at least 2 personnel - one is responsible for sedation only

Documented & accepted hospital protocol Recording

Informed consent


Sedation that short term pain may have long term benefit – reduces the state of awareness

Analgesia – reduces or eliminates the perception of pain

Amnesia – Inability to remember an event or experience (babies do remember the painful experience!)


Practicing Sedation and Analgesia in the ER … that short term pain may have long term benefit


Non pharmacological sedation
Non pharmacological sedation that short term pain may have long term benefit

Parental distraction techniques

Quite environment, toys, books, music

“Hei Doc, tell me what’s going on….”“….don’t take my mom away”


PSA - Medications that short term pain may have long term benefit

Dissociative agent

Inhalational agent

Analgesic agents

Sedative/Hypnotics

Etomidate

Propofol

Opioids

Benzodiazepins

Barbiturates

Ketamine

Nitrous Oxide

Non-opioid

Fentanyl

Ibuprofen

Midazolam

Methohexital

Morphine

Nurofen Advil

Morphine

Oxycode

Tramadol (Atypical opioid)

Topical Analgesia

Morphine

Meperidine?

Emla, AmetopGel, LET, TAC


Continuum depth of Sedation that short term pain may have long term benefit

Purposeful response following repeated or painful stimulation

Unarousable even with painful stimulation

Purposeful response to verbal or tactile stimulation

Normal response to verbal stimulation

Deep

sedation

General

Anesthesia

Level of consciousness

Awake

Minimal sedation (anxiolysis)

Moderate (conscious) sedation

Protective

Reflexes

Present

Present

Present/

potential loss

Probable

loss

Total

loss

Non pharmacologic

Midazolam (P.O./I.N. 0.5 mg/kg)

Ketamine

Fentanyl

Propofol

Combinations

OR only/

Anesthesiologist

Midazolam (P.O./I.N. 0.3 mg/kg)

Nitrous oxide

Chloral hydrate (Triclonam)


THNX that short term pain may have long term benefit


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