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Pediatric Analgesia and Sedation for Painful Procedures. Lou E. Romig MD, FAAP, FACEP Miami Children’s Hospital Emergency Medicine . A.K.A…. In the ED, S edation &A nalgesia beats the heck out of S&M!. Hypersonic screams!. Punctured eardrums!.

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Pediatric Analgesia and Sedation for Painful Procedures

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pediatric analgesia and sedation for painful procedures

Pediatric Analgesia and Sedation for Painful Procedures

Lou E. Romig MD, FAAP, FACEP

Miami Children’s Hospital Emergency Medicine

a k a


In the ED, Sedation&Analgesiabeats the heck out of S&M!


Hypersonic screams!

Punctured eardrums!

Kicks and bites in the …!

Hysterical parents!

This kind of S&M…

sedation analgesia and ems
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 ems6
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.
  • 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.
  • 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.
  • 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
  • Usually done at level of conscious sedation
    • Protective airway reflexes are preserved
    • Maintains own airway
    • Appropriate response to verbal command or stimulation
  • 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
uses for sedation
Uses for Sedation
  • Diagnostic studies
    • CT/MRI
    • Lumbar puncture
    • Joint tap
uses for sedation15
Uses for Sedation
  • Therapeutic interventions
    • Wound management
    • Fracture/dislocation reduction and immobilization
    • Incision and drainage
    • Dental procedures
  • General:
    • 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
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 anesthesia18
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.

Medical treatment for

the relief or prevention of pain.

  • Indication:
    • PAIN
  • Contraindications:
    • Inability to tolerate analgesic agents
    • Procedure requires that patient be able to indicate when he/she feels pain
psychological effects
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
Physiological Effects
  • Release of catecholamines
    • Elevated heart rate
    • Elevated blood pressure
    • Elevated respiratory rate
    • Increased oxygen demand
physiological effects25
Physiological Effects
  • Vagal stimulation
    • Fainting
    • Low heart rate
    • Low blood pressure
    • Breath holding
pain and anxiety
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.
Grunau R. Early pain in preterm infants. A model of long-term effects.Clin Perinatol. 2002 Sep;29(3):373-94, vii-viii.

“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.”






choosing an intervention
Choosing an Intervention
  • Is the patient already in pain?
    • Analgesia
  • Will the procedure cause pain?
    • Analgesia
    • Anesthesia
choosing an intervention31
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
indications for use
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
“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 anesthetics35
“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 anesthetics36
“Caine” anesthetics
  • Toxicity:
    • Dizziness, drowsiness
    • Agitation, confusion, hearing loss
    • Seizures, coma
    • Bradycardia, hypotension
indications for sedation
Indications for sedation
  • Need to facilitate cooperation
  • Need for a complicated or extended procedure
  • Desire for amnesia
  • Relief of muscle spasm
  • 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
  • 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
  • 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
  • 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
  • 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
  • Sedatives do NOT necessarily provide analgesia
  • Vomiting, aspiration
  • Respiratory depression
  • Circulatory depression
  • 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
don t forget
Don’t Forget!

Proper immobilization, positioning and application of ice can be very effective in treating and even preventing pain.

  • Non-narcotic
    • Acetaminophen PO, PR
    • Ibuprofen PO
    • Ketoralac PO, IM, IV
    • No difference demonstrated in effectiveness between ibuprofen and ketoralac
  • Narcotics
    • Morphine IM, IV
    • Demerol IM, IV
    • Fentanyl IV, PO
    • Codeine and analogs PO
    • Morphine and demerol may cause nausea, vomiting, and histamine release
  • 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
Complications of Analgesia
  • Respiratory depression with parenteral administration
  • Sedation
  • Nausea, vomiting
  • Constipation (codeine)
  • Unintentional overdose
  • Addiction is not a consideration



risks to patient
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
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
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
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
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!