Pediatric Pediatric Analgesia and Analgesia and Sedation for Sedation for

Painful Painful ProceduresProcedures

Lou E. Romig MD, FAAP, FACEPMiami Children’s Hospital Emergency Medicine

www.jumpstarttriage.com

A.K.A…A.K.A…

In the ED, Sedation &Analgesia beats the

heck out of S&M!

Hypersonic screams!

Punctured

eardrums! Hysterical parents!

This kind of S&M…

Kicks and

bites in the …!

Why talk about Why talk about these things at these things at

an EMS an EMS conference?conference?

Sedation & Analgesia and EMSSedation & 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 EMSSedation & 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…?If this were your child…?

Objectives:Objectives:

1) State the differences between sedation, anesthesia, and analgesia.

2) Discuss the physiological and psychological effects of pain and anxiety in children.

3) Name 2 sedatives, 2 analgesics and 1 anesthetic commonly used for pediatric outpatient procedures.

Objectives:Objectives:

4) List the most commonly used routes to deliver sedation and analgesia for children, as well as examples of medications used by each route.

5) Review the potential complications of conscious sedation and parenteral analgesia in children and recommended monitoring procedures.

SedationSedation

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

SedationSedation

Usually done at level of conscious sedation

Protective airway reflexes are preserved

Maintains own airway

Appropriate response to verbal command or stimulation

SedationSedation

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 actSedation is a balancing act

Uses for SedationUses for Sedation

Diagnostic studies

CT/MRI

Lumbar puncture

Joint tap

Uses for SedationUses for Sedation

Therapeutic interventions

Wound management

Fracture/dislocation reduction and immobilization

Incision and drainage

Dental procedures

AnesthesiaAnesthesia

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 AnesthesiaIndications 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.

AnalgesiaAnalgesia

Medical treatment forthe relief or prevention of pain.

AnalgesiaAnalgesia

Indication:

PAIN

Contraindications:

Inability to tolerate analgesic agents

Procedure requires that patient be able to indicate when he/she feels pain

Note that youth is Note that youth is not a not a

contraindication contraindication for pain for pain

management!management!

Why treat pain Why treat pain and anxiety inand anxiety in

children?children?

Psychological EffectsPsychological 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 EffectsPhysiological Effects

Release of catecholamines

Elevated heart rate

Elevated blood pressure

Elevated respiratory rate

Increased oxygen demand

Physiological EffectsPhysiological Effects

Vagal stimulation

Fainting

Low heart rate

Low blood pressure

Breath holding

Pain and anxietyPain 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…

Grunau R. Early pain in preterm infants. A model of long-term effects.Grunau R. Early pain in preterm infants. A model of long-term effects.Clin Perinatol. 2002 Sep;29(3):373-94, vii-viii.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.”

Sedation

Anesthesia

Analgesia

?

Choosing an InterventionChoosing an Intervention

Is the patient already in pain?

Analgesia

Will the procedure cause pain?

Analgesia

Anesthesia

Choosing an InterventionChoosing 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 interventionSedation

Anesthesia

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” anestheticsCaine” 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” anestheticsCaine” 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” anestheticsCaine” anesthetics

Toxicity:

Dizziness, drowsiness

Agitation, confusion, hearing loss

Seizures, coma

Bradycardia, hypotension

Sedation

Indications for sedationIndications for sedation

Need to facilitate cooperation

Need for a complicated or extended procedure

Desire for amnesia

Relief of muscle spasm

SedativesSedatives

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

SedativesSedatives

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

SedativesSedatives

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

SedativesSedatives

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

SedativesSedativesBarbiturates

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

ComplicationsComplications

Sedatives do NOT necessarily provide analgesia

Vomiting, aspiration

Respiratory depression

Circulatory depression

PrecautionsPrecautions

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 AnalgesiaIndications for Analgesia

PAIN at any age!

Don’t Forget!Don’t Forget!

Proper immobilization, positioning and

application of ice can be very effective in treating and even preventing pain.

AnalgesicsAnalgesics

Non-narcotic

Acetaminophen PO, PR

Ibuprofen PO

Ketoralac PO, IM, IV

No difference demonstrated in effectiveness between ibuprofen and ketoralac

AnalgesicsAnalgesics

Narcotics

Morphine IM, IV

Demerol IM, IV

Fentanyl IV, PO

Codeine and analogs PO

Morphine and demerol may cause nausea, vomiting, and histamine release

AnalgesicsAnalgesics

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 AnalgesiaComplications of Analgesia

Respiratory depression with parenteral administration

Sedation

Nausea, vomiting

Constipation (codeine)

Unintentional overdose

Addiction is not a consideration

RisksRisks BenefitsBenefits

Risks To PatientRisks 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 CaregiversRisks 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 PatientsBenefits 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 CaregiversBenefits 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 LessonsTake 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 The End.End.Thank Thank You!You!