Pediatric emergency medicine trisk 1076

an additional mechanical apparatus attached to the skin One more recently tested product is a self-contained topical patch containing lidocaine and prilocaine that generates heat once removed from its airtight pouch, allowing for a 20-minute onset of action This product offers the advantage of keeping the medication where it is placed, without the potential for leakage; however, it must also be applied well in advance of the procedure, requiring accurate site choice and potentially higher cost for application at more than one site Finally, recent products that use the combination of vibration and cold to decrease distal sensation through the “gate theory” of pain have been shown to reduce the pain of IV needle insertion similarly to topical analgesic application An example of one of these products is the Buzzy Nerve Blocks Lidocaine can be used for peripheral or regional nerve block if the physician has appropriate knowledge of anatomy and nerve supply to the wound The skin at the nerve site should be anesthetized, and then lidocaine (maximum to mg/kg) should be infiltrated more deeply around the nerve (never into the nerve) in the same manner as with local anesthesia During this infiltration, the physician should aspirate to ensure a blood vessel has not been penetrated inadvertently Examples of commonly used nerve blocks in the ED include digital blocks for finger or toe injuries, mental or infraorbital blocks for lip lacerations, and alveolar blocks for dental pain Femoral nerve block using ultrasound guidance (see Chapter 131 Ultrasound ) offers better and more prolonged analgesia than IV opioids for femur fractures Bier Blocks The preferred technique for fracture reduction at some institutions is a Bier block or “mini-Bier” block With this technique, a limb that is injured and requires a painful procedure is locally anesthetized A double pneumatic tourniquet or two blood pressure cuffs are placed proximal to the injury and inflated in order to exsanguinate the limb and an IV line is placed distal to the tourniquet Lidocaine is then injected into the limb and allowed to diffuse to the local tissues—everything below the tourniquet is anesthetized Please refer to a procedure handbook for more information on the specifics and materials necessary for a Bier block Bupivacaine is no longer recommended for Bier blocks due to risk of significant cardiotoxicity There are risks to this procedure, including seizures, coma, confusion, and cardiac arrest, if the child were to unintentionally receive a massive amount of lidocaine rapidly Three randomly controlled trials involving Bier blocks found no adverse effects among more than 500 procedures Still some physicians prefer to perform the Bier block or mini-Bier block in the operating room, where circumstances can be better controlled NONPHARMACOLOGIC METHODS FOR PAIN CONTROL Regardless of the procedure performed or the medications used during PSA, the patient’s developmental level and acute level of anxiety will directly impact the success of a procedure and the patient’s experience There are many nonpharmacologic methods to decrease the child’s fear and incorporate the family into achieving the therapeutic objectives In general, these methods are low cost, consume very little time, and have few, if any, side effects Thus, nonpharmacologic techniques can be used alone or as adjuncts to sedation and analgesic drug therapy Children need gentle reassurance and carefully chosen words to reduce fear and pain One should keep in mind that young children understand more than they say Avoid casual teasing, condescension, or talking about the child while excluding him or her As many choices as possible should be offered, but only if they are real choices Do not tell a child that something will not hurt unless you are sure that it will not It is important to be honest with the child about any pain or discomfort that he or she will experience Once a child is surprised by a painful stimulus, he or she will become more vigilant and less amenable to distraction or relaxation techniques In general, the time between informing the child about potential discomfort and the actual procedure performance should be brief Long delays between the explanation and the actual procedure increase anticipatory distress prior to the procedure One study showed that an empathic (age-appropriate) explanation of an upcoming needle stick reduced crying among patients compared with a group of children who received impersonal instructions Allowing an older child to read about a procedure and then allowing roleplaying and discussion was helpful in reducing pulse rates, as well as other physiologic and behavioral responses to pain Such explanations and roleplaying are time-consuming, and it is helpful to enlist the child’s parents to assist in these techniques In some EDs, child-life specialists help children with nonpharmacologic methods for pain management including psychological preparation for procedures, “comfort” holds, distraction, and educating staff (and sometimes even families) about the most appropriate language to use for a specific child The strategies employed by child life have a positive impact on patient and family satisfaction, staff satisfaction, and cost Sinha found that for laceration repair, the use of child-life specialists was associated with a reduction in parental perceptions of pain in younger children and a decrease in self-reported anxiety for older children In a 2014 policy statement, the AAP concluded that hospitals should use child-life services as a quality indicator and strive to have child life as part of an integrated family-centered care model Most pediatric centers advocate family member’s presence during painful procedures Research demonstrates that family presence does not increase the pain or distress of the parent or child, nor does it adversely affect the clinicians’ abilities to provide safe and effective care Giving the family the option to remain in the room during procedures and resuscitations increases the family’s overall satisfaction with the visit, and should be incorporated into the plans for PSA Distraction of a child during a painful procedure may help reduce pain and distress This includes having the child perform rhythmic breathing or blowing bubbles Age-appropriate distraction reduces self-reported anxiety and parental perception of pain in children during laceration repair For younger children, parents can also help with singing and storytelling Visually intriguing toys, paintings on the walls or ceiling of a procedure room, and music or videotapes may also distract a young child Music therapy is effective in reducing anxiety and pain for children undergoing procedures, and recent work has also used virtual reality goggles to distract older children during procedures Guided imagery, in which children are coached to imagine a pleasant memory or scenario, may also be helpful For example, one could ask the child to think of the funniest movie he or she has ever seen and to imagine the pain getting less intense with each laugh Or, the child could be asked to imagine the pain as a color that is fading away and is painted over with the child’s favorite color Hypnosis has been used to treat pain in children for several years, and it has been successful in children as young as years of age Hypnosis has proven value for chronic pain syndromes such as migraine headaches or long-term illnesses Hypnosis has also been recommended for the acute management of burns, fractures, and other injuries; however, its use for painful procedures in a busy ED has not been rigorously evaluated Counterstimulation is a technique by which someone repetitively and persistently rubs or touches an area of the body close to the area that is being hurt This technique is based on the gate theory of pain Transmission of pain information from dorsal horn cells occurs through a “gate,” which opens in response to signals from the affected small fibers The gate can be “closed” by large neurons that are stimulated by nonpainful touching or pressing of the skin The theory explains why we rub our elbow when we hit it against something: The rubbing stimulates these large fibers and suppresses the anticipated painful sensation Preliminary studies demonstrate effectiveness of a quickly pulsating device, along with a cold pack, applied to the skin proximal to a venipuncture site using the “gate theory” in order to provide analgesia Restraint should not be used in lieu of appropriate sedation and analgesics for the pediatric patient Although proper restraint of a child for a painful procedure does not always reduce fear or anxiety, it does allow the physician to perform the task better This indirectly reduces pain because fewer attempts may be necessary to accomplish the task One should never attempt a painful procedure on a moving subject! The need for restraint should be explained to the parents, who should not be involved in the actual process Instead, the child might be wrapped in hospital sheets around the torso and extremities, with the parents attempting to calm the child afterward The wrapping technique should be monitored carefully to avoid the uncommon complications of minor bruising, edema, or transient vascular compromise SPECIAL SITUATIONS The Emotionally Labile Child There are a number of issues the clinician faces when caring for an injured child who is known to be emotionally labile This includes children with autism, developmental delay, behavioral disorders, or an adjustment disorder It is important to assess the child’s expected emotional response in a foreign environment, use the social and emotional support available to the ... indicator and strive to have child life as part of an integrated family-centered care model Most pediatric centers advocate family member’s presence during painful procedures Research demonstrates... provide analgesia Restraint should not be used in lieu of appropriate sedation and analgesics for the pediatric patient Although proper restraint of a child for a painful procedure does not always reduce