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Procedural Sedation and Analgesia in the Emergency Department

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

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  1. Procedural Sedation and Analgesia in the Emergency Department Itai Shavit, MD 1

  2. Unfortunately, this is usually not what we see in the ED …

  3. Pain and suffering go together

  4. Acute Pediatric Pain

  5. Children may experience severe pain What if this was your child ?

  6. 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

  7. “Children are not just the people of tomorrow, they are people today” (Janusch Korchak)

  8. 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...."

  9. Pain is an Emergency Relieving pain & anxiety are an ED task!! (today’s standard of care)

  10. We have all experienced pain … PAIN ASSESSMENT

  11. 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

  12. Anxiety decreases pain threshold (Fear makes every pain greater)

  13. Types of pain: Pain on presentation -Due to injury -Due to illness Procedure-related pain (the pain we create)

  14. Pain on presentation 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

  15. Severe pain should be treated ASAP

  16. Morphine?

  17. Procedure-related pain The pain we create! Fracture reduction, Lacerations repair, Urine Cathetherization , Spinal tap, Arthrocentesis, IVs

  18. Procedure-related pain may be sometimes painful but it is always stressful

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

  20. קורס סדציה (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”.

  21. קורס סדציה (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

  22. Sedation – 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!)

  23. Practicing Sedation and Analgesia in the ER …

  24. Non pharmacological sedation Parental distraction techniques Quite environment, toys, books, music “Hei Doc, tell me what’s going on….”“….don’t take my mom away”

  25. PSA - Medications 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

  26. Continuum depth of Sedation 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)

  27. THNX

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