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2013;1:CD001069 Emotionally Labile Child Brown JJ, Gray JM, Roback MG, et al Procedural sedation in children with autism spectrum disorders in the emergency department Am J Emerg Med 2019;37(8):1404–1408 Carlone G, Trombetta A, Amoroso S, et al Intramuscular Dexmedetomidine, a feasible option for children with autism spectrum disorders needing urgent procedural sedation Pediatr Emerg Care 2019;35(6):e116–e117 Medication Errors and Complications Cravero JP, Bilke GT, Beach M, et al; Pediatric Sedation Research Consortium Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium Pediatrics 2006;118:1087– 1096 Joint Commission on Accreditation of Healthcare Organizations 2005 Comprehensive Accreditation Manual for Hospitals: The Official Handbook by the JCAHO Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2005 CHAPTER 130 ■ PROCEDURES THERESA M FREY, MATTHEW R MITTIGA PREPARATION AND ASSESSMENT OF THE CHILD A significant challenge to the effective and efficient performance of procedures in pediatric emergency department (ED) patients is the fear and anxiety generated in both children and their caregivers at the prospect of potentially painful procedures Even when pain can be well controlled, fear can derail even the simplest of procedures Optimal preparation and assessment of the child and their caregivers can allay fears and anxiety and contribute to procedural success and a positive patient and family experience Even relatively short procedures can become prolonged and difficult to successfully complete without accurate assessment and optimal preparation Certified child life specialists are experts in this preparatory/assessment role and have been increasingly used as part of the care team in EDs with significant pediatric patient volumes In the absence of a child life specialist, ED staff should be prepared to provide the needed preparation, support with positioning, and distraction techniques to increase the probability of success The child’s developmental maturity and coping skills should be assessed to determine the capability for understanding, tolerating, and cooperating with the procedure Key considerations for successful preparation of the child and their caregivers include (1) a developmentally appropriate explanation of the procedure using hands-on methods when possible, including pretend medical equipment and models (e.g., dolls); (2) honesty with the child and caregivers about the painful portions of the procedure with details regarding the planned behavioral coping strategies to be employed during the procedure; (3) encouragement of questions about the procedure; and (4) assessment and intervention for parental anxiety, which easily transfers to the pediatric patient if not addressed Pain management and coping strategies might include swaddling or oral sucrose in younger infants and breathing techniques, distraction, and visual imagery in preschool and school-aged children Children are less fearful and distressed when in a sitting position than in a supine position Positioning a child in a caregiver’s lap can be beneficial if the procedure allows Potential distraction items include bubbles, toys that light up, books, videos, conversation with the child, and mobile devices with age-appropriate applications Since younger children are generally in the visual distractor group, something they can see and/or grasp will provide the highest likelihood of successful distraction During medical and trauma resuscitation or other acutely life-threatening situations, ED staff should strive to provide a professional staff member to support the family and to address questions in an ongoing fashion This will allow the medical team to concentrate on the acute care needs of the child while still supporting the family through this difficult situation For patients requiring pharmacologic sedation, caregivers should be informed about expected responses based on the patient’s developmental level, potential effects of sedation, the purpose of monitoring equipment that will be attached to their child, and any anticipated discomfort subsequent to the procedure The assurance that use of these medications can increase safety and may minimize repeated discomfort should be emphasized The medical team should consider whether the ED is the appropriate venue in which to perform the procedure Collaborative discussion with the care team prior to presenting options to the family may be beneficial Points to consider include the developmental assessment of the child, the anticipated length of the procedure, positioning and management of patient movement, and the need for pharmacologic interventions Lengthy procedures or a procedure in a patient with a significant inability to cope may deplete resources and might be more safely performed in the operating suite Consequences and complications of the procedure should be anticipated prior to commencing, with mitigation plans in place as needed, particularly in medically complicated or high-risk patients Aside from procedures necessary to address immediately life-threatening emergencies, assent and support for the procedure should be sought from the child and parents beforehand An informative, efficient discussion of risks, benefits, and alternatives almost always reassures the parents of the need for the procedure Written consent may not be necessary for simple procedures, but standards should be explicitly defined by local ED clinical leadership and hospital policies around which procedures require written consent, what defines an emergency during which written consent can be bypassed, and under what conditions a minor should also assent Finally, prior to initiating a procedure on any patient the use of a team time-out before starting should be promoted as part of the ED safety culture Use of a checklist during the time-out can ensure that the correct procedure is being performed on the correct patient at the correct anatomic location and that adequate supplies are available for the procedure POSITIONING AND RESTRAINTS Indications Restraint should be considered in the performance of those procedures in which excess movement will be detrimental to the safe and successful completion of the procedure Excess movement can lead to patient or medical provider injury, prolonged procedural time, and suboptimal procedural outcomes Physical restraints can be more effective than human restraint and may be necessary in a small proportion of infants, toddlers, and preschool children However, restraint may also carry its own share of psychosocial complications, including increased distress, decreased coping, and lasting memories The risks and benefits of restraint, as well as alternatives, should be weighed appropriately In conjunction with restraint, standard methods of pharmacologic anxiolysis or sedation and local or regional anesthesia are often indicated The use of anxietyreduction techniques by trained staff, typically child life specialists, as well as the continued calm presence of the parents, may be of great benefit to the child Complications Erythema, bruising, or edema at points of contact Vascular compromise (restraint too tight or restraint for excessive time) Mistrust and fear at future medical encounters Airway compromise or musculoskeletal injury (rare except in high-risk patients or with unsafe restraint practice) Procedure With good distraction and creative positioning, some children will be able to complete procedures without physical restraint Use the examination prior to the procedure and the period of cleaning and other involvement with the injury to determine how well the patient may tolerate the procedure If the child is able to remain still during these times, you may be able to avoid restraint altogether By placing a sheet under the child prior to commencement of the procedure, you can start with the least amount of restraint, but move to the bundling wrap quickly should it become necessary Positional Support by Caregiver Often, the separation from a caregiver may evoke a response that sets the procedure on a difficult course Child life and other staff may encourage close positioning of the caregiver (i.e., in the bed next to the child or a chair next to the bed) so that the child feels more connected and safe during the procedure Caregiver presence is often associated with decreased stress, less pain, and ... CHILD A significant challenge to the effective and efficient performance of procedures in pediatric emergency department (ED) patients is the fear and anxiety generated in both children and their... preparatory/assessment role and have been increasingly used as part of the care team in EDs with significant pediatric patient volumes In the absence of a child life specialist, ED staff should be prepared... procedure; and (4) assessment and intervention for parental anxiety, which easily transfers to the pediatric patient if not addressed Pain management and coping strategies might include swaddling