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Procedural Sedation and Analgesia in the Emergency Department

Itai Shavit, MD

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

Pain and suffering go together

Acute Pediatric Pain

Children may experience severe painChildren may experience severe pain

What if this was your child ?What if this was your child ?

Do we really need to treat Do we really need to treat Pediatric pain in the ED?Pediatric pain in the ED?

(Ethics?)(Ethics?)

There is no ethical justification to withhold analgesia when a child is clearly

in pain

““Children are not just the people of Children are not just the people of tomorrow, they are people today” tomorrow, they are people today”

(Janusch Korchak)(Janusch Korchak)

מינהל רפואהמינהל רפואה

מדינת ישראל - משרד הבריאות החטיבה לענייני

בריאות

הנדון: סדציה בילדים על ידי רופא שאינו מרדים

על כל מטפל חלה החובה למזער את הכאב והפגיעה בילדים ...""....בכל האמצעים העומדים לרשותו

2003במאי 13

Pain is an EmergencyPain is an Emergency

Relieving pain & anxiety

are an ED task!!

(today’s standard of care)

We have all experienced pain …We have all experienced pain …

PAIN ASSESSMENTPAIN ASSESSMENT

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

Anxiety decreases pain threshold (Fear makes every pain greater)

Types of pain:Types of pain:

Pain on presentation -Due to injury -Due to illness

Procedure-related pain (the pain we create)

Fractures, Burns, Amputations

Due to injuryDue to injury

Pain on presentationPain on presentation

Due to illnessDue to illness

Peritonitis, Sickle cell crisis, Otitis Media, Migraine

Severe pain Severe pain Severe pain

Severe pain Severe pain

Severe pain should be treated Severe pain should be treated ASAPASAP

The pain we create!The pain we create!

Fracture reduction, Lacerations repair,

Urine Cathetherization , Spinal tap,

Arthrocentesis, IVs

Procedure-related painProcedure-related pain

Procedure-related pain may be sometimes painful

but it is always stressful

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

“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”.

Procedural Sedation and Analgesia Procedural Sedation and Analgesia (PSA) (PSA)

American College of Emergency Physicians, 1998American College of Emergency Physicians, 1998

(מ.ס.קורס סדציהר, תל השומר)

Safe environment resuscitation space, resuscitation equipment

Trained Personnel PALS & Pediatric sedation course trained, at least 2 personnel - one is responsible for sedation only

Documented & accepted hospital protocol Recording

Informed consent

(מ.ס.קורס סדציהר, תל השומר)

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!)

Practicing Sedation and Analgesia in Practicing Sedation and Analgesia in the ER …the ER …

Non pharmacological sedation Non pharmacological sedation Parental distraction techniques

Quite environment, toys, books, music

““Hei Doc, tell me what’s going on….”Hei Doc, tell me what’s going on….”“….don’t take my mom away”“….don’t take my mom away”

PSA - MedicationsPSA - Medications

Opioids Non-opioid Benzodiazepins Barbiturates Etomidate

Propofol

Nitrous Oxide

Ketamine

Analgesic agents Sedative/HypnoticsDissociative

agentInhalational

agent

Fentanyl

Morphine

Midazolam

Meperidine?

Methohexital

Topical Analgesia

OxycodeTramadol (Atypical opioid)

Ibuprofen

Nurofen Advil

Emla, AmetopGel, LET, TAC

Morphine

Morphine

Continuum depth of SedationContinuum depth of Sedation

Level of consciousness

Deep

sedation

General

Anesthesia

Minimal sedation (anxiolysis)

Moderate (conscious) sedation

Protective

Reflexes

Present Present Present/

potential loss

Total

loss

Probable

loss

Awake

Midazolam (P.O./I.N. 0.3 mg/kg)

Midazolam (P.O./I.N. 0.5 mg/kg)

Nitrous oxide

Chloral hydrate

(Triclonam)

Ketamine

Fentanyl

Propofol

Combinations

OR only/

Anesthesiologist

Non pharmacologic

Normal response to verbal stimulation

Purposeful response to verbal or tactile stimulation

Purposeful response following repeated or painful stimulation

Unarousable even with painful stimulation

THNX