Pediatric Analgesia and Sedation for Painful Procedures

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

2. A.K.A… In the ED, Sedation&Analgesiabeats the heck out of S&M!

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

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: • 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. Analgesia Medical treatment for the relief or prevention of pain.

20. Analgesia • Indication: • PAIN • Contraindications: • 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 inchildren?

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. 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.”

29. ? Anesthesia Sedation Analgesia

30. Choosing an Intervention • Is the patient already in pain? • Analgesia • Will the procedure cause pain? • Analgesia • 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 30-60 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