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

Pediatric Analgesia and Sedation for Painful Procedures

Lou E. Romig MD, FAAP, FACEP

Miami Children’s Hospital Emergency Medicine

www.jumpstarttriage.com

a k a

A.K.A…

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

slide3

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.
objectives
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.
objectives9
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
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
sedation11
Sedation
  • Usually done at level of conscious sedation
    • Protective airway reflexes are preserved
    • Maintains own airway
    • Appropriate response to verbal command or stimulation
sedation12
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
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
anesthesia
Anesthesia
  • 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.
analgesia
Analgesia

Medical treatment for

the relief or prevention of pain.

analgesia20
Analgesia
  • 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.
slide28
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.”

slide29

?

Anesthesia

Sedation

Analgesia

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
sedatives
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
sedatives40
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
sedatives41
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
sedatives42
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
sedatives43
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
Complications
  • Sedatives do NOT necessarily provide analgesia
  • Vomiting, aspiration
  • Respiratory depression
  • Circulatory depression
precautions
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
don t forget
Don’t Forget!

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

analgesics
Analgesics
  • Non-narcotic
    • Acetaminophen PO, PR
    • Ibuprofen PO
    • Ketoralac PO, IM, IV
    • No difference demonstrated in effectiveness between ibuprofen and ketoralac
analgesics51
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
analgesics52
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
Complications of Analgesia
  • Respiratory depression with parenteral administration
  • Sedation
  • Nausea, vomiting
  • Constipation (codeine)
  • Unintentional overdose
  • Addiction is not a consideration
slide54

Risks

Benefits

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.
slide61

The End.

Thank You!