Pediatric emergency medicine trisk 1074

to reach a desired depth of sedation, and therefore potentially decrease the risk of sedative adverse effects One should take into account the choice of sedative when deciding to also administer an analgesic Certain sedatives, such as ketamine, have analgesic properties, and additional analgesia may not be necessary when this drug is used Other sedatives not offer any pain control and patients could benefit from concomitant use of an analgesic agent One must be aware that some analgesic medications, in particular opiates, can potentiate the respiratory depression experienced after administration of sedatives Table 129.6 summarizes the advantages and disadvantages of several analgesics used in PSA Sucrose Sucrose is safe and effective in managing pain for infants younger than months of age The effect of sucrose is strongest in the newborn and decreases gradually over the first months of life It is recommended to use a 25% sucrose solution and administer mL orally by allowing the infant to suck on a pacifier Alternatively, use a syringe and apply mL orally to each cheek There are almost no side effects and the dose can be repeated The sucrose should be administered no more than minutes before beginning the painful procedure and it is usually most effective when given for short painful procedures such as heel stick or venipuncture Some clinicians note that an infant may be calmed during a lumbar puncture while sucking continuously on a pacifier dipped in sucrose Opioids Opioid medications are extremely important for treating moderate to severe pain and can be an important adjunct in procedural sedation Most opioids can cause important adverse effects (primarily respiratory depression and hypotension) that are dose related and may be reversed with naloxone if necessary, remembering that reversal of the narcotic-induced side effect will also reverse pain control For this reason, naloxone may be dosed according to level of reversal needed (e.g., mild respiratory depression can be reversed with to 10 mcg/kg) to preserve some level of pain control Because of pharmacokinetic differences in young infants that may predispose them to respiratory depression, these drugs should be used with caution and with reduced doses in infants younger than months of age who are not ventilated mechanically For severe pain from a significant burn, sickle cell crisis, fracture, or other injury, morphine is an excellent choice The usual dosage of morphine is 0.1 to 0.2 mg/kg/dose, titrated to effect and given intravenously over a few minutes The maximum dose is generally 10 mg for opioid-naive subjects, although starting doses of to mg for adolescents are usually sufficient if the medication is titrated upward based on pain symptoms, and may be repeated every to hours The higher dosage, and a dosing interval of every to hours, is suggested for those who take narcotics often (e.g., those with sickle cell disease or cancer) because they may have some tolerance to the drug If needed, a subsequent dose is reduced to 0.05 mg/kg if the patient is moderately sedated Due to a slower metabolism of this medication, young infants under the age of months should receive 0.05 mg/kg every to hours and they should be closely monitored When given intravenously, its effect is almost immediate, with the peak effect occurring in to 10 minutes Patients may experience pruritis due to histamine release and this is not necessarily an allergic reaction Morphine can cause hypotension because of both decreased peripheral vascular resistance and histamine release This is more often a concern in patients with severe injuries, who may be hypovolemic, or in those experiencing histamine release Certainly, the fluid status of an injured child requires careful attention from the ED staff, but pain control should not be withheld until after IV fluids have corrected volume depletion If the child is awake, alert, and screaming in pain, morphine can be given safely as long as the patient is monitored carefully If the patient has persistent hypotension, other agents such as fentanyl can be used to control pain TABLE 129.6 ANALGESICS FOR PROCEDURAL SEDATION IN CHILDREN Fentanyl is a synthetic opioid that should be given at a dose of to mcg/kg/dose intravenously slowly over to minutes It has a rapid onset of action (almost immediately) and a short duration of action (30 to 60 minutes), which makes it useful in the ED Fentanyl is also effective when used intranasally The IN dose is mcg/kg (maximum 100 mcg), its onset is within minutes, and it is well tolerated Fentanyl has several other advantages It is a relatively safe drug and rarely causes hypotension, making it an excellent choice for injured children in severe pain Respiratory depression can occur within minutes of fentanyl administration, but this is reported in only 0.7% of adult patients, some of whom were intoxicated with alcohol There is a greater risk of respiratory depression when fentanyl is coadministered with other sedatives and in infants younger than months of age Apnea occurs even less often, and this may be related to a rapid rate of infusion of fentanyl rather than the dosage Although these adverse effects are serious, they can be reversed with naloxone and avoided if the dosage guidelines are followed and the drug is given slowly Individualized dosing titrated to effect may reduce these side effects Also, equipment and personnel who can manage an obstructed airway should be nearby when fentanyl is used An uncommon event caused by fentanyl is severe thoracic and abdominal muscle rigidity However, this “wooden chest syndrome” has not been reported during procedural sedation, in which lower doses are used and when the drug is administered slowly Most often, this side effect is reversible with naloxone, but succinylcholine and manual ventilation may be required Despite the problems noted, fentanyl remains a valuable analgesic that can be used in the ED when a child has severe pain Fentanyl has been used for safe repair of complicated facial lacerations that might otherwise have required general anesthesia It should be noted that fentanyl causes an unusual tendency for children to reach up and scratch their faces If fentanyl is used for repair of lacerations, restraints may be needed to prevent a child from contaminating a sterile field Even better, the parent can be assigned to scratch the child’s nose if so requested Hydromorphone (Dilaudid) is a semisynthetic agent used for management of moderate to severe pain for children in the ED, as a substitute for morphine and codeine This is often given orally, rectally, or parenterally, and the analgesic effects last to hours It is less sedating than morphine Serious errors have occurred when hydromorphone dosing is confused with morphine dosing No more than 0.015 mg/kg (maximum mg/dose) should be given intravenously for initial dosing Local Agents Lidocaine is an excellent local anesthetic that is used frequently in the ED for wound repair, foreign-body removal, insertion of IV infusion lines or lumbar puncture needles, drainage of abscesses, and arterial puncture Lidocaine without epinephrine is usually administered as a 1% solution (10 mg/mL) or 2% solution (20 mg/mL) at a maximum dosage of to mg/kg/dose (maximum 300 mg) A 0.5% solution is used for infiltration when large volumes are needed or in smaller patients when it is desirable to limit the total dose When vasoconstriction is desired for suturing, lidocaine can be used in combination with epinephrine at a maximum dosage of to mg/kg of lidocaine (maximum 500 mg) For children less than months of age, the maximum dose should be reduced by 30% The traditional teaching is lidocaine should not be combined with epinephrine for use in areas