Pediatric emergency medicine trisk 1077

child at the time of the visit, and determine the need for and choice of medications for sedation and analgesia The parents’ or caregiver’s assessment of the child’s anticipated emotional response is useful in defining the best approach for the procedure Despite an apparent lack of response to usual vocal or calming techniques, many children still well if their caregivers stay near, and if it seems to them that there is less change occurring in their surroundings The route of administration is also an important consideration, in that some children have a strong aversion to manipulation of certain body parts If the child is taking medications already, drug interactions must be considered when choosing a procedural sedative However, if the child’s initial medication has sedative properties (e.g., those found in phenobarbital or benzodiazepines), then simply adding or increasing a dose may be all that is needed Despite the potential for paradoxical reactions in children with emotional disorders, benzodiazepines used in the correct dosage result in better cooperation for procedures In fact, the situation may be worsened by having too little medication to initiate anxiolysis or sedation Propofol has been used successfully for PSA in children with autism spectrum disorder (ASD) with no increase in adverse events compared to children without ASD Ketamine may also cause a severe emotional response in emotionally reactive children A small case series of successful PSA with IM dexmedetomidine (4 mcg/kg) for children with ASD makes this an intriguing option that warrants further study COMPLICATIONS AND ERRORS Most children who receive sedation and analgesia in the ED have a good outcome and benefit from the efforts to reduce pain and anxiety during a procedure However, administration of sedative and analgesic agents to children in the ED always carries some risk to the patient and potential liability for the provider Even with proper patient screening, preparation, and care, adverse events can still occur The overall adverse event rate for PSA in children is less than 10%, and the majority of these are minor, such as hypoxia requiring brief administration of oxygen The serious adverse event rate, such as those requiring a more significant intervention, is even lower, around 3% or less depending on the agent Nonetheless, it is essential that the PSA provider adheres to proper protocol, be thoughtful about the choice of agent, remain vigilant for changes in patient status, and intervene before a minor issue becomes a serious one The needs of the provider or the institution must not be placed ahead of the safety or comfort of the patient A physician should always prepare, and ensure adequate staffing, for a deeper level of sedation than originally planned Medication Errors There is always a chance for error with medications All ED staff, including physicians, nurses, pharmacists, and support staff, should take steps to prevent medication errors Look-alike and sound-alike drugs, sometimes with similar packaging, are contributing factors in some errors Caution should be used in stocking medications Allergic reactions are potential complications with any medications Preventable errors related to medication allergies may occur when the healthcare provider fails to obtain an adequate medical history, fails to read the record, or does not review previously documented allergies Some of the more serious medication errors involve a misplaced decimal point, which can result in a 10-fold error Dosing errors are the leading category of mishaps involving medications and about 10% of these are related to an incorrect weight (obtained or recorded incorrectly) for the child The patient’s weight must be carefully recorded in an obvious location in the record and it is best to record this consistently in kilograms Studies performed on inpatient units have shown that computerized physician order entry systems, particularly those with automated alerts for high- or lowdosage errors, have reduced medication errors by 55% Institutions are required by The Joint Commission and the Centers for Medicaid and Medicare Services (CMS) to establish a list of “high-alert” drugs that would require special or additional checks in their dosing, preparation, and administration; however, all medications should be double checked before they are administered Research shows that 95% of all mistakes are found when someone checks the work of another Having a satellite pharmacy that serves the ED with unit dosing rather than having nurses prepare medications may be beneficial It is interesting to note that, in the hospital setting, 39% of errors are detected before reaching the patient In the ED setting, only 23% of errors are detected before reaching the patient This may be related to the lack of a pharmacist’s involvement in most ED decisions The Joint Commission advocates a “time-out” before any medication is given to verify the correct patient, site, and medications Anticipate complications such as laryngospasm or vomiting Have a backup plan for complications before they arise The Joint Commission emphasizes the concept of “sedation rescue,” which is essential to safe sedation The ability to rescue a patient after an adverse event is also emphasized by AAP guidelines Documentation Careful documentation of the use of sedatives and analgesics is important If an inpatient or outpatient record already exists, there is no need to repeat the information previously documented However, a brief note is recommended to indicate that the chart was reviewed before giving sedative agents A note indicating the child’s presedation status is helpful and there should be a notation that the patient’s condition has not changed since arrival or since the last examination in the record When using sedatives and analgesics, a well-designed, time-based record is essential The use of a separate form or checklist is particularly useful as a supplement to the ED note The checklist may improve efficiency and may serve to remind the caregiver to ask specific questions or perform a specific part of the physical examination The record should indicate any history of allergies or adverse drug reactions, as well as medications used prior to sedation It is wise to place this information near the section for writing the sedation orders so they can be reviewed when medications are ordered The physical examination should focus on the airway and cardiovascular system It is also helpful to document the child’s level of consciousness during the procedure (e.g., how he or she responds to verbal commands or tactile stimulation) Note the patient’s level of consciousness again prior to discharge Discharge instructions must be reviewed with the child’s guardian before the patient is allowed to go home They should include a reminder to parents that the child should not be involved in activities that require coordination, such as bicycle riding or skating, for perhaps 24 hours Adult supervision should be recommended for at least hours Unsupervised bathing and use of electrical devices or other possibly dangerous items should not be permitted for at least hours DISCHARGE MEDICATIONS Children in the ED with painful medical conditions or injuries may continue to experience pain after discharge home Below is a brief summary of frequently used oral outpatient analgesics for mild to moderate pain Acetaminophen Acetaminophen acts centrally on nonopioid receptors in the brain to inhibit prostaglandin synthetase Acetaminophen is a good choice for pain associated with minor trauma or otitis media because it is well tolerated and comes in liquid form, making it easy to give to young children In addition, acetaminophen does not cause bleeding and is unlikely to cause bronchospasm in asthmatics It is dosed at 10 to 15 mg/kg/per dose every hours (with no more than doses/24 hours) and takes effect in 20 to 40 minutes, with a peak effect in hours Rectal administration produces delayed and variable uptake Higher doses may be needed, but clearance may be prolonged so the rectal dose interval should be extended to or hours Single rectal doses of 20 mg/kg produced safe plasma concentrations in preterm neonates In general, high dosages of acetaminophen are usually well tolerated, but therapy in children should not exceed 75 mg/kg/day (60 mg/kg/day in infants and newborns) Acetaminophen has no antiinflammatory effects, and therapeutic doses rarely are associated with side effects in children; overdose, however, can cause liver toxicity Over-thecounter acetaminophen is available in several different concentrations, so parents must be carefully advised about correct dosing NSAIDs Nonsteroidal anti-inflammatory drugs (NSAIDs) are potent inhibitors of the cyclooxygenase (COX) pathway and they prevent the formation of prostaglandin, a known mediator of pain, fever, and inflammation NSAIDs are excellent choices for treating minor pain, such as headache, dysmenorrhea, or musculoskeletal injuries NSAIDs are subject to a ceiling effect, in which a maximum dose is achieved, beyond which there is no additional analgesic effect Advantages of NSAIDs are that they are nonaddictive and not cause respiratory or cardiac depression NSAIDs