EMERGENCY SEDATION AND PAIN MANAGEMENTProcedural sedation and analgesia represents one of the great advances in the maturationof emergency medicine as a discrete specialty within medicine. Once the exclusive domainof the anesthesiologist, sedation and pain management procedures are now a routine partof all emergency department practices. Emergency Sedation and Pain Management is a comprehensive medical textaddressing emergency sedation and analgesia with speciﬁc emphasis on treatment ofthe emergency department patient. The easily accessible, clinically oriented formatallows the reader fast and efﬁcient access to the key points in each chapter. The text presents a clinical approach to the treatment of pain in emergencypatients, including pediatric and adult populations. Analgesia, sedation, andanesthetic techniques are presented in an informative, authoritative, and conciseformat – written and edited by physicians with extensive research as well as clinicalemergency medicine expertise. The chapters are richly supplemented with tables,photographs, and step-by-step illustrations.john h. burton, md, has been the Residency Program Director in EmergencyMedicine and a Professor of Emergency Medicine at Albany Medical College inAlbany, NY, since 2006. From 1999 to 2003, Dr. Burton was the Medical Director forMaine Emergency Medical Services and, from 1995 to 2006, he worked in theDepartment of Emergency Medicine at the Maine Medical Center in Portland. Hewas the founding Research Director in the Department of Emergency Medicine atMaine Medical Center. Dr. Burton’s areas of research interest are procedural sedation and analgesia,emergency medical services, and management of cardiovascular emergencies. He haspublished extensively in the emergency medicine literature on these and relatedtopics. He has received awards and peer recognition throughout his academic careernoting a commitment to the specialty of emergency medicine. Dr. Burton completed medical school at the University of North Carolina at ChapelHill in 1992 and residency training at the University of Pittsburgh Afﬁliated Residencyin Emergency Medicine in 1995.james miner, md, facep, has been the Director of Performance Improvementand the Associate Research Director in the Department of Emergency Medicine atHennepin County Medical Center since 1999 and is an Associate Professor ofEmergency Medicine at the University of Minnesota Medical School. Dr. Miner has performed extensive research in the areas of pain management andprocedural sedation in the Emergency Department and has published numerousmanuscripts on these topics. He is an associate editor of Academic EmergencyMedicine. Dr. Miner completed medical school at Mayo Medical School in 1996 and residencytraining at the Hennepin County Medical Center in Emergency Medicine in 1999.
Emergency Sedationand Pain ManagementEdited byJOHN H. BURTONAlbany Medical CollegeJAMES MINERUniversity of Minnesota School of Medicine
ContentsAcknowledgments page ixList of Contributors xiSECTION ONE. OVERVIEW AND PRINCIPLES IN EMERGENCYANALGESIA AND PROCEDURAL SEDATION 1 1 Emergency Analgesia Principles James Miner and John H. Burton 1 2 Emergency Procedural Sedation Principles John H. Burton and James Miner 5 3 Analgesic and Procedural Sedation Principles Unique to the Pediatric Emergency Department Susan Fuchs 11 4 Pain and Analgesia in the Infant Michelle P. Tomassi 18 5 Provider Bias and Patient Selection for Emergency Department Procedural Sedation and Analgesia Knox H. Todd 25 6 Federal and Hospital Regulatory Oversight in Emergency Department Procedural Sedation and Analgesia Sharon Roy 30 7 Nursing Considerations in Emergency Department Procedural Sedation and Analgesia Tania D. Strout and Dawn B. Kendrick 38SECTION TWO. ANALGESIA FOR THE EMERGENCY PATIENT 43 8 Pharmacology of Commonly Utilized Analgesic Agents Eustacia Jo Su 43 9 Patient Assessment: Pain Scales and Observation in Clinical Practice Tania D. Strout and Dawn B. Kendrick 5510 Pathways and Protocols for the Triage Patient with Acute Pain Paula Tanabe 67 v
vi Contents 11 Patients with Acute Pain: Patient Expectations and Desired Outcomes David E. Fosnocht, Robert L. Stephen, and Eric R. Swanson 75 12 Analgesia for the Adult and Pediatric Multitrauma Patient Wayne Triner 79 13 Analgesia for the Emergency Department Isolated Orthopedic Extremity Trauma Patient Michael A. Turturro 87 14 Analgesia for Selected Emergency Eye and Ear Patients Matthew G. Dunn 91 15 Analgesia for the Emergency Headache Patient James Miner 96 16 Analgesia for the Emergency Chest Pain Patient Carl A. Germann and Andrew D. Perron 103 17 Analgesia for the Emergency Back Pain Patient Donald Jeanmonod 109 18 Analgesia for the Acute Abdomen Patient Martha L. Neighbor 120 19 Analgesia for the Renal Colic Patient Allan B. Wolfson and David H. Newman 127 20 Analgesia for the Biliary Colic Patient Allan B. Wolfson and David H. Newman 131 21 Analgesia for the Chronic Pain Patient James Miner 135 22 Outpatient Analgesia following Acute Musculoskeletal Injury John C. Southall 141 SECTION THREE. PROCEDURAL SEDATION FOR THE EMERGENCY PATIENT 147 23 Patient Assessment and Preprocedure Considerations Baruch Krauss and Steven M. Green 147 24 Monitoring for Procedural Sedation Baruch Krauss 152
Contents vii25 Pharmacology of Commonly Utilized Sedative Agents Eustacia Jo Su 15926 Procedural Sedation for Pediatric Laceration Repair Mark G. Roback 16827 Procedural Sedation for Pediatric Radiographic Imaging Studies Nathan Mick 17328 Procedural Sedation for Brief Pediatric Procedures: Foreign Body Removal, Lumbar Puncture, Bone Marrow Aspiration, Central Venous Catheter Placement Michael Ciccarelli and John H. Burton 17929 Procedural Sedation for Adult and Pediatric Orthopedic Fracture and Joint Reduction James Miner and John H. Burton 18530 Procedural Sedation for Electrical Cardioversion Christopher J. Freeman 19031 Procedural Sedation for Brief Surgical Procedures: Abscess Incision and Debridement, Tube Thoracostomy, Nasogastric Tube Placement Carl Chudnofsky 195SECTION FOUR. TOPICAL, LOCAL, AND REGIONAL ANESTHESIAAPPROACH TO THE EMERGENCY PATIENT 20532 Selected Topical, Local, and Regional Anesthesia Techniques Douglas C. Dillon and Michael Gibbs 20533 Topical Anesthesia Considerations for Pediatric Peripheral Intravenous Catheter Placement William T. Zempsky 22434 Regional Anesthesia for Adult and Pediatric Orthopedic Fracture and Joint Reduction Douglas C. Dillon and Michael Gibbs 23035 Regional Anesthesia for Dental Pain Kip Benko 23736 Local Anesthesia for Laceration Repair Joel M. Bartﬁeld 250
viii Contents SECTION FIVE. SPECIAL CONSIDERATIONS FOR EMERGENCY PROCEDURAL SEDATION AND ANALGESIA 255 37 Sedation and Analgesia for the Prehospital Emergency Medical Services Patient Michael Dailey and David French 255 38 Induction Agents for Rapid Sequence Intubation of the Emergency Department Patient Joseph Clinton and Arleigh Trainor 260 39 Sedation and Analgesia for the Critical Care Patient Richard Riker and Gilles L. Fraser 268 Index 277
AcknowledgmentsI am indebted to many professional and life mentors, including Darrell Sechrest; GerryUnks, PhD; Fred Hansen, MD; Abby Wolfson, MD; Don Yealy, MD; Herb Garrison, MD,MPH; Bud Higgins, MD; Mara McErlean, MD; and Vince Verdile, MD. I stand on theshoulders of mentors and friends (there have been many others). Thank you. This effort could not have transpired without the inspiration and constant support ofthe most important people of my life: Phyllis Burton-Sechrest, Allison Burton, CarolineBurton, and Tracy Burton. To you, I dedicate my efforts. John H. BurtonI am grateful for the guidance and support of the mentors who have shaped my career,especially Kenneth Watanabe, PHD, and Michelle Biros, MS, MD. I dedicate this work tomy loving family, Stephanie Miner, Isaac Miner, Natalie Miner, and Stella Miner, whosesupport made this possible. James MinerThe editors gratefully acknowledge the efforts of Tim Sweeney, MD, Maine MedicalCenter, Portland, for his contribution of a number of outstanding medical illustrationsfor this text. These illustrations are displayed as ﬁgures and color plates throughoutthe text. ix
ContributorsJoel M. Bartﬁeld Joseph ClintonOfﬁce of Graduate Medical Education Professor of Emergency MedicineAlbany Medical College Department of Emergency Medicine43 New Scotland Avenue, MC 50 University of Minnesota Medical SchoolAlbany, NY 12208-3479 Chief, Department of Emergency MedicineEmail: bartﬁj@mail.amc.edu Hennepin County Medical Center Minneapolis, MN 55415Kip Benko Email: email@example.comThe Mercy Hospital of Pittsburgh1400 Locust Street Michael DaileyPittsburgh, PA 15219 Department of Emergency MedicineEmail: Kippster1@aol.com Albany Medical College 43 New Scotland Avenue, MC 139John H. Burton Albany, NY 12208-3479Department of Emergency Medicine Email: firstname.lastname@example.orgAlbany Medical College Douglas C. Dillon43 New Scotland Avenue, MC 139 Department of Emergency MedicineAlbany, NY 12208-3479 Latter Day Saints (LDS) HospitalEmail: email@example.com Salt Lake City, UT 84132 Email: firstname.lastname@example.orgCarl ChudnofskyDepartment of Emergency Medicine Matthew G. DunnAlbert Einstein Medical Center Department of Emergency MedicineKorman B-6 Glens Falls Hospital5501 Old York Road Glens Falls, NY 12801Philadelphia, PA 19141 Email: email@example.comEmail: firstname.lastname@example.org David E. FosnochtMichael Ciccarelli Division of Emergency MedicineDepartment of Emergency Medicine University of UtahAlbany Medical College 30 North 1900 East Rm AC21843 New Scotland Avenue, MC 139 Salt Lake City, UT 84132Albany, NY 12208-3479 Email: email@example.com xi
xii List of ContributorsGilles L. Fraser Donald JeanmonodMaine Medical Center Department of Emergency MedicinePortland, ME 04102 Albany Medical CenterEmail: firstname.lastname@example.org 43 New Scotland Avenue Albany, NY 12208Christopher J. Freeman Email: email@example.comDepartment of Emergency Medicine Dawn B. KendrickAlbany Medical College Division of Emergency Medicine43 New Scotland Avenue, MC 139 Department of PediatricsAlbany, NY 12208-3479 University of Alabama at BirminghamEmail: firstname.lastname@example.org MTC 205 1600 7th Avenue SouthDavid French Birmingham, AL 35233-1711Department of Emergency Medicine Email: email@example.comAlbany Medical College43 New Scotland Avenue, MC 139 Baruch KraussAlbany, NY 12208-3479 Children’s Hospital BostonEmail: firstname.lastname@example.org Division of Emergency Medicine 300 Longwood AvenueSusan Fuchs Boston, MA 02115Professor of Pediatrics Email: email@example.comFeinberg School of MedicineNorthwestern University Nathan MickDivision of Pediatric Emergency Medicine Department of Emergency MedicineAssociate Director 47 Bramhall StreetChildren’s Memorial Hospital Maine Medical CenterChicago, IL 60614 Portland, ME 04102Email: firstname.lastname@example.org Email: email@example.com James MinerCarl A. Germann Department of Emergency MedicineMaine Medical Center Hennepin Medical CenterDepartment of Emergency Medicine 701 Park Avenue South22 Bramhall Street Minneapolis, MN 55415Portland, ME 04102-3175 Email: Miner015@umn.eduEmail: firstname.lastname@example.org Martha L. NeighborMichael Gibbs 1 Hawks Hill CourtDepartment of Emergency Medicine Lafayette, CA 94549-1900Maine Medical Center Email: email@example.comPortland, ME 04102 David H. NewmanEmail: firstname.lastname@example.org Director of Clinical ResearchSteven M. Green Assistant Professor of Clinical MedicineLoma Linda University Medical Center Department of Emergency MedicineDepartment of Emergency Medicine A-108 St Luke’s/Roosevelt Hospital Center11234 Anderson Street 1111 Amsterdam AvenueLoma Linda, CA 92354 New York, NY 10025Email: email@example.com Email: firstname.lastname@example.org
List of Contributors xiiiAndrew D. Perron Eustacia Jo SuDepartment of Emergency Medicine Chief, Pediatric Emergency Medicine SectionMaine Medical Center Associate Professor, Emergency MedicinePortland, ME 04102 and Pediatrics Oregon Health Sciences UniversityRichard Riker 3181 SW Sam Jackson Park RoadChest Medicine Associates CDW-EM335 Brighton Avenue, Suite 200 Portland, OR 97201Portland, ME 04102-2354 Email: email@example.comEmail: Rikerr@mmc.orgMark G. Roback Eric R. SwansonProfessor, Department of Pediatrics Division of Emergency MedicineUniversity of Minnesota Medical School University of UtahAssociate Director, Division of Pediatric 30 North 1900 East Rm AC218 Emergency Medicine Salt Lake City, UT 84132University of Minnesota Children’s Hospital/Fairview76 Variety Club Research Center Tim SweeneyMMC 814, 420 Delaware Street SE Department of Emergency MedicineMinneapolis, MN 55455 Maine Medical CenterEmail: firstname.lastname@example.org Portland, ME 04102Sharon Roy Email: email@example.comDepartment of Emergency MedicineHennepin County Medical Center Paula Tanabe701 Park Avenue South Department of Emergency Medicine and theMinneapolis, MN 55415 Institute for Healthcare StudiesEmail: firstname.lastname@example.org Northwestern University 259 E. Erie, Suite 100John C. Southall Chicago IL 60611Chief of Emergency Services Email: Ptanabe2@nmff.orgMercy Hospital144 State Street Knox H. ToddPortland, ME 04101 Professor of Emergency MedicineEmail: email@example.com Director, Pain and Emergency Medicine InstituteRobert L. Stephen Department of Emergency MedicineDivision of Emergency Medicine Beth Israel Medical CenterUniversity of Utah Albert Einstein College of Medicine30 North 1900 East Rm AC218 First Avenue at 16th StreetSalt Lake City, UT 84132 New York, NY 10003 Email: firstname.lastname@example.orgTania D. StroutMaine Medical Center Michelle P. TomassiDepartment of Emergency Medicine Department of Emergency MedicineResearch Nurse Albany Medical Center321 Brackett Street 43 New Scotland Avenue, A-139Portland, ME 04102 Albany, NY 12208-3478Email: email@example.com Email: firstname.lastname@example.org
xiv List of ContributorsArleigh Trainor The Mercy Hospital of PittsburghDepartment of Emergency Medicine 1400 Locust StreetHennepin County Medical Center Pittsburgh, PA 15219Minneapolis, MN 55415 Email: email@example.com Allan B. WolfsonWayne Triner Professor of Emergency MedicineDepartment of Emergency Medicine 230 McKee Place, Suite 500Albany Medical College Pittsburgh, PA 1521343 New Scotland Avenue, MC 139 Email: firstname.lastname@example.orgAlbany, NY 12208 William T. ZempskyMichael A. Turturro Associate Director, Pain Relief ProgramClinical Professor of Emergency Medicine Connecticut Children’s Medical CenterUniversity of Pittsburgh School of Medicine 282 Washington StreetVice Chair and Director of Academic Affairs Hartford, CT 06106Department of Emergency Medicine Email: email@example.com
SECTION ONE. OVERVIEW AND PRINCIPLES IN EMERGENCY ANALGESIA AND PROCEDURAL SEDATION1 Emergency Analgesia Principles James Miner and John H. Burton SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN CONSIDERATIONS PAIN MANAGEMENT SUMMARY BIBLIOGRAPHY suppression of the endorphin system with associatedSCOPE OF THE PROBLEM vegetative changes and physiologic dependence. It isPain is the presenting complaint for up to 70% of visits partially due to the early success of morphine that furtherto the emergency department (ED). There are a myriad advances in analgesic agents, aside from general anes-of strategies to treat and diagnose pain. The effective thesia, have been slow relative to other areas of medicine.strategies are those with adequate and timely pain relief There are a wide variety of approaches to the treatmentwithout adverse effects. of pain and very few single approaches that have clearly In 1992, the World Health Organization developed a been demonstrated as superior to others. Developingclinical guideline for the treatment of acute pain. This consistent and effective approaches to the management ofguideline includes basic instructions to select an a wide variety of painful conditions can optimize aappropriate pain medication for the patient’s pain physician’s ability to treat patients with pain. In addition,intensity, individualize the dose by titration of opioids, using effective analgesic strategies will allow one toand concomitantly provides adjuvant analgesic drugs as address the analgesic needs of patients while decreasingco-analgesics or to counteract side effects. the potential for side effects. It has been shown that patients frequently receiveinadequate analgesia in the ED. Oligoanalgesia, the in- CLINICAL ASSESSMENTadequate treatment of pain, frequently occurs in the ED,especially in those patients at the extremes of age and An accurate recognition and assessment of a patient’smembers of minority and ethnic groups. pain is the central aspect of effective pain management Treatment of pain is essentially a simple process, and a and is essential to any effective analgesic strategy. Thiswide variety of agents and techniques are available that process is subjective and complex with many of theare generally effective. Morphine has been recognized as a factors involved in an individual’s pain experience notbasic treatment for pain throughout the modern era of fully understood.allopathic medicine. It is effective, easy to obtain, and has Acute pain is deﬁned as an unpleasant sensory andnever been expensive. However, morphine has severe side emotional experience associated with actual or potentialeffects when overused, speciﬁcally in the acute setting tissue damage as well as activation of neurochemicalwith respiratory depression, hypotension, and a decreased receptor and mediator responses (Table 1-1).ability to report worsening symptoms. Issues with the Acute pain is primarily a subjective concept. Objectivechronic use of morphine, as with all opiates, include observations (grimacing, tachycardia) may be present, 1
2 Overview and Principles in Emergency Analgesia and Procedural Sedation Table 1-1. Opioid receptors, activities, and subsequent endorphin responses to acute pain Receptor Activity Endorphin Mu1 Euphoria, supraspinal analgesia Beta-endorphin Mu2 Respiratory depression, CV, and GI effects Beta-endorphin Delta Spinal analgesia Enkephalin Kappa Spinal analgesia, sedation, feedback inhibition Dynorphin Epsilon Hormone Beta-endorphin Gamma Psychomimetic effects, dysphioria Table 1-2. Pathway/barriers to effective pain assessment and treatment Phase Barrier Complaint/assessment Patient communication Physician bias Patient and physician concerns about the consequences of treatment Treatment Patient medical condition Physician knowledge of treatment modalities Adverse events Plan for ongoing Physician knowledge of treatment modalities treatment Patient compliance Adverse effects of medicationsbut these signs are often absent. As a consequence, of pain in the face of cultural differences is a difﬁcult, yetpatient pain assessment remains an indirect estimation important challenge to overcome in order to treat painby the treating physician. It is, therefore, important to adequately.use a consistent vocabulary in describing an assessment It should also be noted that many physicians haveof a patient’s pain. This process will allow patient encountered patients who have altered a prescription,ﬁndings to be communicated accurately and precisely have lost pain medications, seem to have pain out ofwhile a systematic treatment practice is implemented. proportion to their illness or injury, or who ignore follow- Because pain is assessed almost completely through up clinic appointments and return to the ED repeatedly.patient report, patients who have difﬁculty communi- These experiences can make it easy to view a patient’scating are at risk of oligoanalgesia due to under- report of pain with skepticism. Such observations andappreciation of their pain. Groups at risk include infants experiences, like the physician’s assessment of patientand children, patients whose cultural background differs pain, are signiﬁcantly dependent on verbal and nonverbalsigniﬁcantly from the treating physician’s, and patients subjective communication between the physician andwho are developmentally delayed, cognitively impaired, patient. This reality creates a substantial potential forunder severe emotional stress, or mentally ill. inaccurate interpretations of patient motives in clinical Unfamiliar or unrecognized attempts by the patient to conditions where the patient pain experience is largelyexpress pain may be misinterpreted by the physician, subjective (e.g., back pain) with minimal opportunityleading to a poor interaction and an unclear assessment for objective clinical assessment with modalities such asof the patient’s pain (Table 1-2). The accurate assessment radiographic imaging or laboratory testing.
Emergency Analgesia Principles 3 chronic pain states. Chronic pain is uncommonly associ-PAIN CONSIDERATIONS ated with signs of sympathetic nervous system activity.Acute pain follows injury and usually resolves as the The treatment of acute and chronic pain is different,injury heals. Acute pain may be, but is not always, asso- and confusion between the two leads to poor manage-ciated with objective physical signs of autonomic nervous ment of patients. Acute pain should be approached withsystem activity such as tachycardia, hypertension, dia- the intention of providing relief to a limited degree,phoresis, mydriasis, and pallor. When the cause of acute individualized to each patient, with a plan to taperpain is uncertain, establishing a diagnosis is the priority of medications as symptoms improve. Chronic painthe emergency physician. Symptomatic treatment of pain assumes a baseline level of pain that is best treated with ashould be initiated while the diagnostic evaluation is consistent approach to minimize baseline discomfortproceeding. In general, it is inappropriate to delay anal- and minimize the adverse effects of both pain and paingesic use until a diagnosis has been made. It is unlikely, treatment on the patient’s lifestyle.and unproven in medical literature, that treatment with ED personnel commonly identify patients who are0.1 mg/kg of morphine, or another analgesic equivalent, thought to seek pain medications, usually opioids, forwill mask signs or symptoms of progressive disease such illegitimate purposes. Drug addiction and prescriptionthat the effective treatment of pain will confound the abuse occur throughout medicine specialties, and thediagnostic approach. true prevalence of addiction and drug-seeking behaviors Chronic pain is pain that has persisted after the usual in the ED population is unknown.time of tissue healing has passed. This is clearly a vague When patients are undergoing treatment with opioiddeﬁnition with a great deal of ambiguity between acute and medications, the physician should be aware of the Intractable pain Brief procedural pain Sedation/anesthesia – Sedation/anesthesia – procedural sedation Oral/IM opioids Opioids IV opioids – nonsevere pain – titration required – titration unlikely – severe pain – quantity of pain – unknown quantity of pain medication required medications required established Peripheral nerve blocks as appropriate Nonselective NSAIDS, COX-2 inhibitors, tramadol Nonpharmacologic measures – assurance – stabilize situation Acetaminophen Pain assessment Figure 1-1. A generalized approach to the treatment of acute pain.
4 Overview and Principles in Emergency Analgesia and Procedural Sedationpotential for development of physical dependence and/ SUMMARYor tolerance. The clinician should be cautious, however,not to label the patient as an ‘‘addict’’ who is merely Pain is the most common complaint in the ED. Having aphysically dependent or tolerant of medications. Such consistent, integrated, and well-planned approach willscenarios have been characterized with the term iatro- optimize the experience for patients as well as medicalgenic pseudoaddiction. These patients have opioid doses providers.that are either too low or spaced too far apart to relievepain, and subsequently develop behavior resembling BIBLIOGRAPHYpsychological dependence. 1. Pain management in the emergency department. Ann Emerg Med 2004;44(2):198. 2. Rupp T, Delaney KA. Inadequate analgesia in emergencyPAIN MANAGEMENT medicine. Ann Emerg Med 2004;43(4):494–503. 3. Fosnocht DE, Swanson ER, Barton ED. Changing attitudesA generalized approach to the treatment of acute pain about pain and pain control in emergency medicine.should be consistently applied to patient encounters Emerg Med Clin North Am 2005;23(2):297–306.(Figure 1-1). Such an approach will optimize the 4. Jones JS, Johnson K, McNinch M. Age as a risk factor forpotential for effective analgesia across a broad range of inadequate emergency department analgesia. Am J Emerg Med 1996;14(2):157–160.painful conditions. 5. Friedland LR, Kulick RM. Emergency department analge- For injured patients whose pain progresses past the sic use in pediatric trauma victims with fractures. Anninitial acute phase and in patients with chronic pain, Emerg Med 1994;23(2):203–207. 6. Green CR, et al. The unequal burden of pain: Confrontingclose follow-up with a single practitioner can be an racial and ethnic disparities in pain. Pain Med 2003;4important aspect of their ongoing care. This practice (3):277–294.allows for the adoption of consistent approaches and the 7. Miner J, et al. Patient and physician perceptions as risksystematic trial of various strategies to determine a factors for oligoanalgesia: A prospective observational study of the relief of pain in the emergency department.strategy that best suits a given patient. Acad Emerg Med 2006;13(2):140–146. It is common for patients in the midst of ongoing 8. Bartﬁeld JM, et al. Physician and patient factors inﬂuencingprimary care to present with pain in the ED, or for the treatment of low back pain. Pain 1997;73(2):209–211.patients who have conditions warranting follow-up with 9. Cooper-Patrick L, et al. Race, gender, and partnership in the patient–physician relationship. JAMA 1999;282(6):583–589.a single practitioner to seek care from multiple sources 10. Merskey H. The taxonomy of pain. Med Clin North Amincluding the ED. If possible, these patients should be 2007;91(1):13–20.provided with a short course of medication and have 11. Thomas SH, et al. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patientsclose follow-up arranged. In patients who are unwilling with abdominal pain: A prospective, randomized trial.or unable to obtain follow-up with a single physician, J Am Coll Surg 2003;196(1):18–31.the clinician should emphasize the development of a 12. Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine atconsistent patient analgesic strategy with clear expecta- 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med 2005;46(4):362–367.tions to minimize both undertreatment and the adverse 13. Weissman DE, Haddox JD. Opioid pseudoaddiction – aneffects of long-term opioid use. iatrogenic syndrome. Pain 1989;36(3):363–366
2 Emergency Procedural Sedation Principles John H. Burton and James Miner SCOPE OF THE PROBLEM PSA VS CONSCIOUS SEDATION Locations for PSA Practice The PSA Depth of Consciousness Spectrum CLINICAL ASSESSMENT PAIN/SEDATION CONSIDERATIONS PAIN/SEDATION MANAGEMENT Common ED PSA Agents FOLLOW-UP/CONSULTATION CONSIDERATIONS SUMMARY BIBLIOGRAPHY provision of a number of additional elements includingSCOPE OF THE PROBLEM relaxation of affected muscle groups and tissues adjacentProcedural sedation and analgesia (PSA) in the emer- to injured structures, reduction of patient anxiety, and asgency department (ED) is a common component of the a means to improve the broad experience of the proce-modern practice of emergency medicine. The concepts dure encounter not only for the patient but also forinherent to PSA, however, are not new to emergency patient family members and health-care providers alike.care for the sick and wounded. More recently, the understanding and practice of ED Medical accounts from authors as early as Hippo- PSA has beneﬁted from a great deal of interest fromcrates have included descriptions of painful procedures, researchers and clinicians. This interest has produced asuch as orthopedic dislocation and fracture reduction, in substantial amount of disseminated research, empirictheir accounts of the stabilization of patients with acute observations, and practical experience that havemedical and traumatic conditions. Along with these advanced the collective understanding of the roles anddescriptions, physicians have often described the use beneﬁts of procedural sedation.of certain techniques or adjuncts to assuage the pain Minimal, moderate, and deep sedation have all beenassociated with therapeutic procedures. described in the ED setting. Emergency patients fre- Historical depictions of procedure patients have fre- quently have conditions that require pain and complexquently included images of caregivers providing alcohol procedures. Unlike most patients who are undergoingor inhalational agents to alleviate procedure-related pain sedation in other settings, patients in the ED have un-and suffering. These concepts have become inherent to predictable NPO status, often have concurrent, severeour collective view of the role of medical caregivers as systemic disease, and usually are in severe pain beforeboth prescribing treatment as well as relief of pain and the procedure begins. In addition, concurrent eventssuffering throughout history. and time/bed constraints cannot be predicted in the ED. The rationale for administration of analgesic and/or As a consequence, ED PSA has evolved into a specializedsedative agents has generally relied upon the reduction of practice, responding to these many challenges, withpain and suffering. Modern medical practice recognizes unique approaches not common to other settings andthe importance of PSA as being equally important for the patients. 5
6 Overview and Principles in Emergency Analgesia and Procedural Sedation Table 2-1. PSA practice policy components Medical provider scope of practice and credentialing Patient PSA consent Standardized patient assessment, monitoring, and preparation practices for intended depth of consciousness Suggested PSA drug dosing strategies Patient history and physical examination documentation prior to procedure Documentation of medical procedure and patient monitoring data Discharge criteria following PSA Standards for routine reporting of adverse PSA-related eventsPSA VS CONSCIOUS SEDATION The PSA Depth of Consciousness Spectrum Many health-care locations will organize PSA clinicalThe term ‘‘procedural sedation and analgesia’’ has sup- practice guidelines based on categorical assessments ofplanted the often misused and misinterpreted historical expected sedation depth. PSA practitioners should rec-expression ‘‘conscious sedation.’’ In clinical practice, the ognize that a spectrum exists for the depth of patientconcepts implied with the use of PSA are less misleading sedation during any PSA encounter. This spectrum canto both the patient and the medical provider. In addition, be categorically characterized with levels that wouldthe use of the term PSA in clinical practice more accu- typically include minimal, moderate, and deep sedationrately captures the intent of this practice: sedation and/or (Figure 2-1). The distant end of the sedation depthanalgesia for an acute medical intervention with the depth spectrum would be occupied by a general anesthesiaof sedation and analgesia largely dependent on factors level of consciousness.dictated by the patient’s needs. Minimal sedation generally refers to a patient who retains a near-baseline level of alertness with the abilityLocations for PSA Practice to follow commands in an age-appropriate fashion.There are many locations within health-care facilities Minimal sedation is usually performed for procedureswhere PSA may take place. The areas with greatest that require compliance but are typically less painfulactivity are typically located within the hospital and with the use of local anesthesia. Typical light sedationwould include the ED, outpatient surgery units, radiol- procedures might include procedures such as lumbarogy, gastroenterology, and the intensive care unit (ICU). puncture, evidentiary exams, simple fracture reductions Each PSA site will have its unique patient population in combination with local anesthesia, and abscess inci-and procedures in addition to a unique set of caregivers sion and drainage. During minimal sedation, cardio-delivering care within this setting. The principles for vascular and ventilatory functions are usuallyPSA practice should not be ﬂuid across any collection of maintained, although patients should be monitored forhealth-care sites. Rather, procedural sedation practice inadvertent oversedation to deeper levels with oxygenshould be promulgated within a predetermined set of saturation monitors and close nursing supervision.clinical guidelines and requirements that emphasizes Agents typically utilized for minimal sedation includepatient PSA needs, patient safety, and provider training fentanyl, midazolam, and low-dose ketamine.speciﬁc to the intended level of consciousness depth as As one progresses along the sedation continuum to awell as the procedure (Table 2-1). PSA practice policies moderate sedation depth, levels of impaired conscious-should speciﬁcally address provider credentialing, doc- ness progress with the onset of eyelid ptosis, slurredumentation, patient consent, monitoring, and discharge speech, and delayed or altered responses to verbal sti-criteria for PSA patients in all areas. muli. Moderate sedation is performed on patients who
Emergency Procedural Sedation Principles 7 General Light Moderate Deep anesthesia Clinical signs Awake Responds to voice Responds to pain No response Relaxed Lid ptosis No gag reflex Slurred speech No speech Adverse event risk Pain Hypoventilation Apnea Aspiration Emesis Hypoxia Hypotension Airway obstruction Figure 2-1. The depth of consciousness spectrum for procedural sedation.would beneﬁt from either a deeper level of sedation to moderate sedation – the difference being the intendedaugment the procedure or would beneﬁt from amnesia level of sedation. Monitoring for deep sedation is theof the event. Patients usually have an intact airway and same as for moderate with oxygen saturation, cardiac,maintain ventilatory function without support. As with and blood pressure assessments augmented by directminimal sedation, inadvertent oversedation to deeper observation of the airway.levels can occur and appropriate monitoring including End tidal carbon dioxide (ETCO2) has also beenoxygen saturation, cardiac, and blood pressure assess- described in ED PSA, but its utility over direct ventila-ments should be done throughout the sedation with tion observation remains unclear. Deeply sedateddirect observation of the patient’s airway throughout the patients can develop respiratory depression but generallyprocedure. Agents used for moderate sedation in the ED maintain a patent airway and adequate ventilation.include propofol, etomidate, ketamine, and the combi- Patients sedated to this level can progress to a level ofnation of fentanyl and midazolam. sedation consistent with anesthesia and there is some As patient depth of consciousness progresses into a evidence that this may occur more frequently in patientsdeep sedation, the patient response to verbal commands intended to undergo deep sedation than in patients whois substantially impaired with preservation of response are going to undergo moderate sedation.to painful stimuli as well as preservation of airway A categorization of general anesthesia depicts aprotective reﬂexes. Deep sedation is performed on patient unresponsive to all stimuli as well as the absencepatients who would beneﬁt from a deeper level of of airway protective reﬂexes. Although it is acknowl-sedation in order to complete the procedure for which edged that deep sedation can inadvertently result in athey are receiving sedation. Amnesia of the procedure is level of sedation consistent with anesthesia, this is notsimilar between moderate and deep sedation, and it is typically the goal of ED PSA. Patients who progress to annot necessary to sedate patients to a deep level only to unintended level of sedation consistent with anesthesiaobtain amnesia of the procedure. Deep sedation gener- are unable to be aroused with verbal or painful stimuli.ally is achieved in the ED with the same agents as The ability to independently maintain ventilatory
8 Overview and Principles in Emergency Analgesia and Procedural Sedationfunction is usually impaired, and patients often require relief, anxiolysis, event amnesia, and sedation. The PSAassistance in maintaining a patent airway. Since patients intervention should be characterized as one with ancan quickly progress to this level using the agents typical emphasis on the balance between the intended beneﬁtsof moderate and deep sedation, physicians performing and the potential for PSA-related complications for anymoderate and deep sedation must be prepared to pro- given encounter allowing for the potential that manyvide ventilatory support until the patient has regained patients may experience discomfort despite the use of aconsciousness. PSA-augmented approach. Recent work with bispectral (BIS) monitoring has Patient monitoring should be a standardized processadded an objective assessment to the traditional un- for all PSA encounters. Moderate sedation and deepderstanding of the sedation depth spectrum during PSA sedation encounters should routinely include bloodand general anesthesia. Although much insight has been pressure, heart rate, hemoglobin-oxygen saturation, re-attained for the application of BIS ﬁndings to the general spiratory rate, and depth of sedation monitoring. Manyanesthesia patient, the implications and adaptability of practices have also begun routine ventilation monitoringthis work to the PSA patient are less clear. Precise levels with capnography. Capnography offers the beneﬁt ofof consciousness captured by the BIS monitor have more precise and sensitive monitoring of ventilationvarying degrees of correlation with clinically observed depth and rate through ETCO2 detection.moderate to deep levels of consciousness. As a conse- Depth of sedation is best monitored utilizing a stan-quence, the application of BIS monitoring technology to dardized sedation assessment scale (see Figure 2-1). ThePSA practice remains investigative. most common and clinically relevant complications during PSA encounters are adverse respiratory events such as apnea, hypoxemia, and airway obstruction.CLINICAL ASSESSMENT Therefore, the greatest emphasis for health-care providerPSA guidelines should include a history of present illness training and patient monitoring should be directedand physical examination for each patient. The pre- toward the prevention, detection, and treatment ofprocedure assessment should include consideration of adverse respiratory events.the patient age and any comorbidity that would impactthe selection of agents or dosing. PAIN/SEDATION CONSIDERATIONS The patient assessment should include considerationof the baseline airway status, including the American With the exception of ketamine, ED PSA sedativeSociety of Anesthesiologists’ (ASA) classiﬁcation of the medications have minimal to no inherent analgesicpatient as potentially uncomplicated or complicated properties. As the majority of sedation procedures will(Table 23-1). The ASA classiﬁcation and the patient’s involve a substantial amount of pain, most PSAage may prompt consideration for a more conservative encounters should offer a standardized analgesicagent selection and/or dosing strategy. The Mallampati approach to ensure proper attention to patient painscore is often employed as an assessment guide to assess prior to, during, and after any ED procedure.the potential for airway complications (discussed in The dosing of analgesic agents should be standardizedChapter 23). in a weight-based fashion. A typical approach should An informed consent document should be routinely include initial dosing of an analgesic agent based uponused for encounters where the expected depth of con- the patient’s preprocedural pain. Typical analgesicsciousness will exceed minimal sedation. As PSA consent agents will include morphine sulfate, hydromorphone,is obtained, the patient should be informed of any and fentanyl (Table 2-2). Selection of a speciﬁc analgesicpossible risks of the procedure, including potential should take into consideration the patient’s prioradverse complications and speciﬁc alternatives to the experience with similar analgesics as well as the desiredtreatment plan. The PSA consent should also assist the duration of clinical affects.patient in understanding that PSA for any given patient Patients who require longer periods of analgesia, suchmay or may not meet the patient’s expectations for pain as those with fractures, will beneﬁt from strategies
Emergency Procedural Sedation Principles 9 Table 2-2. Commonly utilized agents population. In the ED setting, the most common PSA for ED PSA procedures will be painful fracture and/or dislocation reduction maneuvers. These procedures typify encoun- Analgesia agents ters where optimum patient relaxation and analgesia are Fentanyl a beneﬁt to patients as well as providers. Morphine sulfate The selection of a proper PSA agent should rely upon Hydromorphone the consideration of a number of patient and procedure- related factors. The anticipated degree of muscle relax- Sedation agents ation and analgesia required for the procedure should be Midazolam contemplated. The expected duration of the procedure Propofol is of critical importance. Any anticipated positioning or Methohexital maneuvering of the patient may lend certain agent Etomidate selections more appropriate. Finally, the expectations of Ketamine the patient and medical consultants taking part in the procedure should be considered as well.emphasizing longer-acting agents, such as morphine or There remains a great deal of variance in ED PSA agenthydromorphone. These patients may also beneﬁt from selection and dosing strategies. Provider experience asintegration of patient-controlled elements such as well as institution or medical consultant preferences maypatient-controlled analgesia (PCA) pumps. Regardless of substantially inﬂuence individual approaches. An ‘‘evi-the analgesic agent selected, the analgesia approach dence-based’’ approach is now possible in clinical practiceshould be a continuous observational process with given the many reviews and investigations published intitration of additional medication in accordance with the medical literature.the ongoing patient needs. The ongoing titration of an analgesic agent during Common ED PSA Agentssedation procedures should be approached with caution. Agents commonly utilized for adult and pediatric EDIntravenous analgesics have inherent risks for ventilatory PSA include midazolam, etomidate, propofol, ketamine,depression as well as hemodynamic compromise. The and methohexital (Table 2-2).simultaneous titration of an analgesic and sedative agent Until recently, midazolam has been the PSA agentadds a compounded risk of these events during proce- that clinicians are most familiar with. Midazolam offersdural sedation as well as an element of confusion as to the beneﬁt of a rapid onset and low incidence of car-the agent or combination of agents responsible should diovascular complications in the ED PSA population.an adverse event occur. However, the utilization of shorter-acting sedative Selected procedures such as cardioversion or foreign agents has increased substantially, largely as a conse-body removal may be viewed as events in which the quence of physician familiarity with these medicationsaddition of an analgesic agent is of limited beneﬁt. In as induction agents in addition to many publishedsuch events, the PSA approach is simpliﬁed signiﬁcantly investigations in the medical literature.by the reduction of agents that place the patient at risk Short-acting sedative agents, speciﬁcally methohex-for adverse hemodynamic or respiratory events. ital, etomidate, and propofol, have consistently been demonstrated to confer similar or, in many cases, improved patient and provider experiences in the EDPAIN/SEDATION MANAGEMENT PSA setting. Adverse event rates associated with theseTypical PSA procedures in the adult and pediatric latter agents have not been characterized as substantiallypopulation might include incision and drainage of higher than the risk traditionally attributed to mid-abscess, fracture and/or dislocation reduction, laceration azolam. The current medical evidence has demonstratedrepair, and foreign body removal. Electrical cardiover- safety proﬁles associated with these agents comparablesion is a procedure commonly undertaken in the adult to midazolam.
10 Overview and Principles in Emergency Analgesia and Procedural Sedation An advantage of midazolam compared to short-acting may be deemed in the patient’s best interests. Generalsedative agents is the relatively light levels of sedation guidelines and participation in a planned approach toproduced with low-dose midazolam. In contrast, these patients is another beneﬁt of a multidisciplinedmethohexital, etomidate, and propofol will confer oversight process for ED PSA.moderate or deep sedation levels for nearly all encoun-ters. Since most ED-based PSA encounters require levels SUMMARYof sedation in the moderate to deep range, this argumentin favor of midazolam likely has little clinical application ED providers and patients beneﬁt from standardizedto the majority of ED patients. institutional and ED PSA practices. Concerns for patient Common arguments expressed in favor of shorter- safety should remain foremost in the provision of EDacting sedative agents promote the view that shorter PSA services. Medical providers responsible for PSAperiods of impaired levels of consciousness confer less practice encounters, particularly practices that routinelyrelative risk for adverse respiratory events, at the same confer levels of deep sedation, should be vigilant in theirtime offering the beneﬁt of substantially reduced moni- training and preparation for adverse hemodynamic andtoring times. The latter issue has gained a great deal of respiratory events.favor and pertinence with increasing ED patient volumesplacing great demands on ﬁxed ED personnel resources. BIBLIOGRAPHY 1. American Society of Anesthesiologists, Task Force onFOLLOW-UP/CONSULTATION Sedation and Analgesia by Non-Anesthesiologists. PracticeCONSIDERATIONS guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96:1004–1017.A diverse medical provider group should be responsible 2. American Academy of Pediatrics. Committee on Drugs, Section of Anesthesiology. Guidelines for monitoring andfor development, maintenance, and ongoing review of management of pediatric patients during and after sedationED PSA practices for any given site. This approach is of for diagnostic and therapeutic procedures. PEDSparticular importance in locations where moderate and 1992;89:1110–1115.deep levels of patient sedation are frequently utilized. 3. Clinical policy for procedural sedation and analgesia in the emergency department. American college of emergencyConsultants routinely include providers with expertise physicians. Ann Emerg Med 1998; 663–677.in anesthesiology, pediatric, and radiology services. 4. Green SM, Krauss B. Procedural sedation terminology:Additional contributing services might include indivi- Moving beyond ‘‘conscious sedation.’’ Ann Emerg Medduals with orthopedics, plastics/reconstructive surgery, 2002;39(4):433–435. 5. Agrawal D, Manzi SF, Gupta R, Krauss B. Preproceduraland cardiology expertise. The goal of such a multi- fasting state and adverse events in children undergoingdisciplined group should be to enable a process of procedural sedation and analgesia in a pediatric emergencyensuring patient safety as well as ongoing performance department Ann Emerg Med 2003;42:636–646. 6. Joint Commission on Accreditation of Healthcare Organi-and evolution of PSA practices. zation. Standards for moderate and deep sedation and Selected patients may be deemed inappropriate for anesthesia hospital accreditation standards. Oakbrook Ter-ED PSA. These individuals may be considered to have an race, Illinois, 2002; Tx:2–Tx.2.4. 1, pp. 108–111.elevated risk for adverse events to such a degree that an 7. Miner JR, Biros MH, Seigel T, Ross K. The utility of bispectral index in procedural sedation with propofol inalternate approach of delaying or relocating the inter- the emergency department. Acad Emerg Med 2005;12:vention and sedation to an alternate time or location 190–196.
3 Analgesic and Procedural Sedation Principles Unique to the Pediatric Emergency Department Susan Fuchs SCOPE OF THE PROBLEM CLINICAL ASSESSMENT Presedation Assessment PAIN/SEDATION CONSIDERATIONS Pain Assessment in Pediatric Patients The Pediatric-Friendly ED as a Method of Distraction Personnel and Training Preprocedural Fasting Children with Special Health-Care Needs FOLLOW-UP/DISCHARGE CONSIDERATIONS SUMMARY BIBLIOGRAPHY allows for retention of protective airway reﬂexes andSCOPE OF THE PROBLEM spontaneous respirations.Analgesia and sedation of infants, children, and ado- There are numerous guidelines that exist for proce-lescents occur on a daily basis in pediatric emergency dural sedation and analgesia (PSA) in children, includ-departments (EDs) across the country. Some of the most ing those developed for sedation by nonanesthesiologistsimportant aspects of safely providing pain relief and/or by the American Society of Anesthesiologists and theanalgesia for painful procedures or sedation/anxiolysis American Academy of Pediatrics (AAP).for nonpainful procedures in children are The American College of Emergency Physicians has a an understanding of the deﬁnitions used for sedation clinical policy on procedural sedation and analgesia of children (PSA), as well as a policy on pharmacologic agents used proper presedation assessment in pediatric PSA. methods of pain assessment Since the Joint Commission on Accreditation of the presence of properly trained personnel and Healthcare Organization (JCAHO) developed standards monitoring devices for pain management and sedation, hospitals that are age-appropriate equipment certiﬁed by this organization must adhere to these guide- postprocedure assessment and discharge instructions. lines. The premise of these guidelines is to enhance pain assessment, patient safety, and to assure that PSA is being The terminology commonly used includes those performed consistently within the hospital, no matter thedeﬁned by the American Society of Anesthesiologists location: radiology, ED, patient ﬂoor, or procedure suite.(ASA) for minimal sedation or anxiolysis, moderatesedation, deep sedation, and general anesthesia. An CLINICAL ASSESSMENTappropriate addition to this structure for the pediatricpopulation is dissociative sedation, which is the trance- There are numerous pediatric patient scenarios that maylike state and analgesia induced by ketamine. This state require PSA in an ED. This includes simple analgesia for a 11
12 Overview and Principles in Emergency Analgesia and Procedural Sedationnondisplaced fracture, anxiolysis to decrease apprehension One concern with observational assessment is it is oftenof venipuncture, sedation for a painless procedure such difﬁcult to determine if the behavior is owing to pain oras a CT scan, and sedation for a painful procedure such as distress/agitation.a displaced fracture reduction. The appropriate selection Physiologic measurements of pain include tachycar-of agents is dependent upon the level of anxiolysis, dia, pupil dilatation, diaphoresis, and peripheral vaso-sedation, or pain relief required for the individual constriction. However, these can also occur because ofclinical encounter. fear, anxiety, or crying. Although a change of 10–20% in heart rate, respiratory rate, or blood pressure is associ-Presedation Assessment ated with pain, no pain assessment tool relies solely onA focused history and physical examination should these parameters. For children less than 3 years of age,include questions about past medical history, medica- the FLACC score is an observational pain assessmenttions, allergies, and prior sedation/analgesia or anes- tool that is commonly utilized (Figure 3-1).thesia experiences. The time of the last solid food intake, For children of age 3 and above, the ‘‘FACES’’ scalesoral intake, and clear liquids should be determined, and have been found to be an easy, well-accepted, reliable, anddecisions made about method and timing of sedation valid method of pain self-reporting. The Wong-Bakermay need to be adjusted. FACES Pain Rating Scale is often used for children between A thorough assessment of the airway for potential pro- the ages of 3 and 18, and consists of 6 faces ranging fromblems should be performed. This assessment should smiling to crying (Figure 3-2). This scale can be used withinclude evaluation for a small mandible, large tongue, brief age-appropriate verbal explanations and has beenshort neck, loose teeth, or limited neck mobility. A physical interpreted in several languages. The smiling face is scoredstatus classiﬁcation, such as that developed by the ASA, as zero, whereas the crying face is scored as 5.may serve to categorize the pediatric patient with regard to Another reliable and valid scale is the Bieri Scale, usedongoing illnesses and medical problems that would suggest for children 3–12 years of age. This scale consists ofa cautious approach toward PSA encounters. seven faces, showing a neutral expression (scored as 0) Consent for PSA should be obtained from the parent or to a face with a painful expression (scored as 6). Oneguardian. The method of drug administration, the actions concern with using a scale with a happy smiling face asof the drug(s), risks, as well as adverse events during and compared to one with a neutral face is that the painafter PSA should be routinely explained beforehand. score is higher with the former. No matter which scale is used, the key point is that the same scale should be used in the ED and throughout the hospital.PAIN/SEDATION CONSIDERATIONS For older children as well as adults, a visual analogPain Assessment in Pediatric Patients scale (VAS) is commonly used (Figure 3-3). The VASOne of the most important aspects of providing pain relief consists of a horizontal or vertical line with a descriptionto children is to understand how to assess the presence of pain at each end (usually no pain on one end with theand severity of pain and the relief of pain in infants and worst pain on the other). Marks are present on the scalechildren. Pain can be assessed in children using physio- at equal intervals, typically at 1 cm intervals, with eachlogic or behavioral observation as well as self-report. mark corresponding to a number along the scale. Since pain is a subjective experience, self-reporting is Studies have shown that when using a 10 cm VAS withfavored. Even children as young as 3 years old can use children, a change of 10 mm is interpreted by the patientself-reports by the use of pain-rating tools. Observa- as clinically signiﬁcant.tional pain assessment is used when the child cannotself-report, or it can be used to supplement physiologic The Pediatric-Friendly ED as a Method ofmeasures and self-reporting. Distraction It should be noted that health-care professionals Because anxiety and fear may play a large role in anyconsistently underestimate a child’s pain, as do parents, child’s ED experience, simple methods of distractionyet the parents are closer to the child’s own pain rating. can be built into the ED or made readily available
Sedation in the Pediatric Department 13 Categories Scoring 0 1 2 Faces No particular Occasional Frequent to expression or grimace or constant smile frown, quivering chin, withdrawn, clenched jaw disinterested Legs Normal position Uneasy, restless, Kicking, or legs or relaxed tense drawn up Activity Lying quietly, Squirming, Arched, rigid or normal position, shifting back jerking moves easily and forth, tense Cry No crys (awake Moans or Crying steadily, or asleep) whimpers; screams or sobs, occasional frequent complaint complaints Consolability Content, relaxed Reassured by Difficult to occasional console or touching, comfort hugging or being talked to, distractable Note: Each of the five categories is scored from 0–2, with a total score between zero and ten. Figure 3-1. FLACC Scale. 0 1 2 3 4 5 NO HURT HURTS HURTS HURTS HURTS HURTS LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST Alternate coding 0 2 4 6 8 10Figure 3-2. Wong-Baker FACES Scale. (From Hockenberry MJ. Wong’s essentials of pediatric nursing, 7th edn. St. Louis, MO: Mosby,2005, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.)
14 Overview and Principles in Emergency Analgesia and Procedural Sedation No pain Worst pain 1. Skilled medical personnel to administer the medication. 2. An individual skilled in airway management and 0 1 2 3 4 5 6 7 8 9 10 cardiopulmonary resuscitation. 3. An individual speciﬁcally assigned to watch the patient during and after the procedure. ThisFigure 3-3. Visual Analog Scale (VAS) for the assessment of pain. includes monitoring and documenting the cardio- respiratory status, watching for chest rise, head(a ‘‘distraction box’’). Distraction involves focusing a position, and following pulse oximetry. Thechild’s attention away from the procedure. This can be as person monitoring the patient must be able tosimple as having child-friendly wallpaper or objects on assist in any supportive or resuscitative measuresthe ceiling, such as mobiles or kites, that a child can focus (providing basic pediatric life support).on (Figure 3-4). A television, with appropriate movies or 4. All settings must have age- and size-appropriateprogramming popular with children, is a great distraction equipment available including oxygen, suctiontool. Depending on the procedure, having a child or apparatus and catheters, bag-mask ventilationparent blow bubbles, blow a pinwheel, or look into a device, airway adjuncts, intubation equipment,kaleidoscope may provide a helpful distraction (Figure 3- reversal medications, IV equipment (if not already5). Older children and adolescents may prefer to listen to in place), IV ﬂuids, and resuscitation medications.music or play a hand-held video game.Personnel and Training Preprocedural FastingAccording to the AAP Committee on Drug Guidelines Preprocedural fasting remains an area of controversy forfor Monitoring, the management of patients during and pediatric patient sedation and analgesia in the ED.after sedation for diagnostic and therapeutic procedures Guidelines have been developed for elective proceduresshould routinely include the following: by the ASA and AAP to reduce the risk of pulmonaryFigure 3-4. Child-friendly wallpaper can serve as a distraction for children in the ED. (For color reproduction, see Color Plate 3.4.)
Sedation in the Pediatric Department 15 Figure 3-5. Toys can serve as visual distracters to allow for a less-threatening examination for children in the ED. (For color reproduction, see Color Plate 3.5.)aspiration of gastric contents. The AAP and ASA agree between a preprocedural fasting state and adverse eventsthat there should be no oral intake of clear liquids for in the ED setting.2 hr prior to the procedure for any age infant or child. Ultimately, the routine preprocedural assessmentThese ASA guidelines assert that the length of NPO should include a query regarding time of last food andstatus should be 6 hr after infant formula or a light meal, liquid intake. The implications of this history should beand 4 hr after breast milk, whereas the AAP guidelines evaluated against the risks and beneﬁts of the plannedadvise that infants 5 months and under should have no depth of sedation and the urgency of the situation.milk or solids for 4 hr, infants 6–36 months no milk orsolids for 6 hr preprocedure, and those older than 36 Children with Special Health-Care Needsmonths should NPO for 8 hr. Of note, the Canadian Children with special health-care needs represent aAnesthesiologists’ Society has indicated that an NPO growing number of patients seen in the ED, especially inrule of no ﬂuid intake for periods beyond 3 hr prior to tertiary care institutions. Although the initial assessmentsurgery is unnecessary. of these children is no different when compared to the The extrapolation of elective procedure practices to the nonspecial needs population, some of these children willemergency setting and population remains a point of have comorbidities and illnesses suggesting signiﬁcantcontention. The primary issue in the ED is that one is risk for analgesic and sedation practices.often faced with an emergency procedure, such as a Information regarding the patients’ current medica-fracture reduction, yet the child does not meet the fasting tion is important to predict any adverse drug interac-guidelines owing to the nature of the unplanned event. tions. Asking the parents about prior experiences with There have been several recent studies considering sedation can be beneﬁcial, as these may provide infor-preprocedural fasting and adverse events in pediatric PSA. mation revealing agents that have previously been usedThree studies, from 3 different institutions with 3,420 for success or complications.patients of ages ranging from 5 days to 32 years, have The pain assessment of the special health-caredemonstrated that there appears to be no association needs child should be adjusted for a developmental
16 Overview and Principles in Emergency Analgesia and Procedural Sedationage-appropriate level. If the patient is nonverbal, use of age-speciﬁc equipment, and discharge criteria should bean infant score, such as the FLACC Scale, may be routine in all pediatric patient analgesia and sedationnecessary. In addition, the parents may be able to assist encounters.in describing some of the child’s pain behaviors orfacial expressions. BIBLIOGRAPHY Monitoring requirements for these children may 1. Krauss B, Green SM. Procedural sedation and analgesia inrequire the addition of cardiac rhythm assessment for children. Lancet 2006;367 (9512):766–780.children with cardiovascular problems. After the pro- 2. Doyle L, Colletti JE. Pediatric procedural sedation. Pediatrcedure, these children may require monitoring for a Clin North Am 2006;53:279–292.longer period than typically utilized to guard against an 3. Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation inenhanced risk for respiratory depression. Discharge children. Ann Emerg Med 2004;44(5):460–471.criteria should still be met, although reaching some of 4. American Society of Anesthesiologists, Task Force on Sedationthe child’s baseline behaviors may depend on the par- and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesi-ents’ assessment. ology 2002;96(4):1004–1017. 5. American Academy of Pediatrics, Committee on Drugs. Guidelines for monitoring and management of pediatricFOLLOW-UP/DISCHARGE CONSIDERATIONS patients during and after sedation for diagnostic and therapeutic procedures: Addendum. Pediatrics 2002;110Speciﬁc discharge criteria for children following seda- (4):836–838.tion events should include the following: 6. EMSC Grant Panel on Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency 1. Cardiovascular function and airway patency are Department. Clinical policy: Evidence-based approach to satisfactory and at baseline. pharmacologic agents used in pediatric sedation and 2. The patient is easily arousable and protective analgesia in the emergency department. Ann Emerg Med 2004;44:342–377. reﬂexes are intact. 7. American College of Emergency Physicians, Clinical 3. The patient can talk (if age appropriate). Policies Subcommittee on Procedural Sedation and 4. The patient can sit up unaided (if age appropriate). Analgesia. Clinical policy: Procedural sedation and 5. The patient has returned to the presedation level analgesia in the emergency department. Ann Emerg Med 2005;45:177–196. of responsiveness. 8. American Academy of Pediatrics, Committee on Psycho- 6. The child’s hydration status is adequate. social Aspects of Child and Family Health, and American Pain Society, Task Force on Pain in Infants, Children, and A reliable adult should be given discharge instructions Adolescents. The assessment and management of acutefor the pediatric patient at the time of discharge from pain in infants, children, and adolescents. Pediatricsthe ED. These should note that the child may be drowsy 2001;108:793–797. 9. Askin DF, Wilson D. Health problems of newborns. Infor a few hours, the adult should not leave the child Wong’s essentials of pediatric nursing, 7th edn, ed. MJunattended in a car seat, and the child should be pro- Hockenbery. St Louis, MO: Elsevier Mosby, 2005, pp. 244–hibited from unattended swimming or bathing for 8 hr. 247.Postdischarge feeding should include precautions con- 10. Merkel SI, Shayevitz JR, Voepel-Lewis T, Malviya S. The FLACC: A behavioral scale for scoring postoperative paincerning the avoidance of a heavy meal for a few hours, as in young children. Pediatr Nurs 1997;23:293–297.some children will have mild nausea after PSA. 11. Wong DL, Baker CM. Pain in children: Comparison of assessment scales. Pediatr Nurs 1988:14:9–17. 12. Powell CV, Kelley A-M, Williams A. Determining theSUMMARY minimum clinically signiﬁcant difference n visual analog pain score for children. Ann Emerg Med 2001;37:28–31.Over the years, emergency physicians are increasingly 13. Soud TE Rogers JS. Nonpharmacologic intervention forasked to provide sedation and analgesia to pediatric pain relief. In Manual of pediatric nursing, ed. TE Soud, JS Rogers. St Louis, MO: Mosby, 1998.patients for numerous diagnostic and therapeutic pro- 14. Rusy LM, Weisman SJ. Complementary therapies for acutecedures. Adherence to existing guidelines for patient pediatric pain management. Pediatr Clin North Amassessment, medical personnel, patient monitoring, 2000;47(3):589–599.
Sedation in the Pediatric Department 1715. Roback MG, Bajaj L, Wahen JE, Bothner J. Preprocedural 17. Hoffman GM, Nowakowski R, Troshynski TJ, Berens RJ, fasting and adverse events in procedural sedation and Wesiman SJ. Risk reduction in pediatric procedural analgesia in a pediatric emergency department: Are they sedation by application of an American Academy of related? Ann Emerg Med 2004;44:454–459. Pediatrics/American Society of Anesthesiologists process16. Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural model. Pediatrics 2002;109:236–243. fasting state and adverse events in children undergoing 18. Sacchetti A, Turco T, Carraccio C, Hasher W, Cho D, procedural sedation and analgesia in a pediatric emergency Gerardi M. Procedural sedation for children with special department. Ann Emerg Med 2003;42:636–646. health are needs. Pediatr Emerg Care 2003;19:231–239.
4 Pain and Analgesia in the Infant Michelle P. Tomassi SCOPE OF THE PROBLEM CLINICAL ASSESSMENT Deﬁnition of Pain in Infants Development of Nociception PAIN CONSIDERATIONS Pain and Memory Pain Assessment in the Infant Pain Scales for Infants PAIN MANAGEMENT Nonpharmacologic Interventions Pharmacologic Interventions Topical and Injected Local Anesthetics FOLLOW-UP/CONSULTATION CONSIDERATIONS SUMMARY BIBLIOGRAPHY This inability to verbalize pain contributes to the failureSCOPE OF THE PROBLEM of health-care professionals to recognize and treat painPain in infants poses a major challenge for health pro- aggressively in infants.fessionals. Although infants are uniquely vulnerable to It has also been hypothesized that pain perceptionpain and its consequences, pain is less adequately con- occurs in a less-organized fashion in the infant than thetrolled in this patient population than in any other. child or adult. Pain is a combination of sensory (dis-Many reasons account for the undertreatment of pain in criminative) and emotional (affective) components. Theinfants with the most common problem being a paucity sensory component of pain is deﬁned as nociception.of knowledge regarding pain and analgesia for the infant Nociception incorporates the physiologic and behavioralpopulation. responses of infants to a painful stimulus but not the cognitive responses that are part of pain perception. Consequently, health-care professionals are required toCLINICAL ASSESSMENT rely on physiologic and behavioral responses whenDeﬁnition of Pain in Infants assessing pain in an infant. Finally, the IASP deﬁnitionThe International Association for the Study of Pain indicates that pain is an association based on previous(IASP) has deﬁned pain as ‘‘an unpleasant sensory and actual or potential tissue damage. In most neonates andemotional experience associated with actual or potential infants, no opportunity has existed for gaining previoustissue damage or described in terms of such damage’’ experience with pain recognition.(from reference 3). It has been suggested that this deﬁ-nition is inappropriate for infants. Development of Nociception The interpretation of pain is subjective and infants Health-care professionals have historically believed thatlack the ability of self-report in the traditional sense. infants are unable to feel pain because of inadequately18