EMERGENCY SEDATION AND PAIN MANAGEMENT - PART 6 pps

mediated pain, or neuropathic pain not responding to typical treatments or not following typical patterns, referral to a pain specialist may be a preferred intervention for the development of a chronic pain management strategy. SUMMARY The treatment of chronic pain require s a differen t approach than acute pain. Patients with chronic pain require multi- modal pain treatments and have variable responses to therapies. Helping the patient through acute-on-chronic exacerbations, and leading them to (or a return to) a consistent chronic pain management strategy can help these patients fi nd effective tr eatments, eliminate ineffective strategies, and gain a sense of control over their pain. BIBLIOGRAPHY 1. Portenoy RK, Ugarte C, Fuller I, Haas G. Population- based survey of pain in the United States: Differences among white, African American, and Hispanic subjects. J Pain 2004;5(6):317–328. 2. Verhaak PF, Kerssens JJ, Dekker J, Sorbi MJ, Bensing JM. Prevalence of chronic benign pain disorder among adults: A review of the literature. Pain 1998;77(3):231–239. 3. Baker K. Chronic pain syndromes in the emergency department: Identifying guidelines for management. Emerg Med Australas 2005;17(1):57–64. 4. MacFarlane BV, Wright A, O’Callaghan J, Benson HA. Chronic neuropathic pain and its control by drugs. Pharmacol Ther 1997;75(1):1–19. 5. Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999;354(9186):1248–1252. 6. Puke MJ, Wiesenfeld-Hallin Z. The differential effects of morphine and the alpha 2-adrenoceptor agonists clonidine and dexmedetomidine on the prevention and treatment of experimental neuropathic pain. Anesth Analg 1993;77 (1):104–109. 7. Backonja M, Beydoun A, Edwards KR, et al. Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus: A randomized controlled trial. JAMA 1998;280(21):1831–1836. 8. Watson CP. Antidepressant drugs as adjuvant analgesics. J Pain Symptom Manage 1994;9(6):392–405. 9. Onghena P, Van Hou denhove B. Antidepressant-induced analgesia in c hronic non-malignant pain: A meta-analy sis of 39 placebo-controlled studies. Pain 1992;49(2): 205–219. 10. McQuay H, Carroll D, Jadad AR, Wiffen P, Moore A. Anticonvulsant drugs for management of pain: A system- atic review. BMJ 1995;311(7012):1047–1052. 11. Rowbotham M, Harden N, Stacey B, Bernstein P, Magnus- Miller L, for the Gabapentin Postherpetic Neuralgia Study Group. Gabapentin for the treatment of postherpetic neuralgia: A randomized controlled trial. JAMA 1998;280 (21):1837–1842. 12. Mao J, Price DD, Hayes RL, Lu J, Mayer DJ, Frenk H. Intrathecal treatment with dextrorphan or ketamine potently reduces pain-related behaviors in a rat model of peripheral mononeuropathy. Brain Res 1993;605 (1):164–168. 13. Mao J, Price DD, Mayer DJ. Thermal hyperalgesia in association with the development of morphine tolerance in rats: Roles of excitatory amino acid receptors and protein kinase C. J Neurosci 1994;14(4):2301–2312. 140 Analgesia for the Emergency Patient 22 Outpatient Analgesia following Acute Musculoskeletal Injury John C. Southall SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN CONSIDERATIONS PAIN MANAGEMENT FOLLOW-UP CONSIDERATIONS SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM Painful musculoskeletal injuries are undertreated in the emerge ncy department (ED). The Joint Commission on Accred itation of Healthcare Organizations states tha t ‘‘unrelieved pain has adverse physical and psycho- logical effect’’ and that pain should be ‘‘assessed in all patients.’’ Despite this, an analys is of the ED component of the National Center for Health St atistics National Hospital Ambulatory Medical Care Survey showed that only 59% of patients with orthopedic injuries had documented pain scores. Perhaps more concerning, in acute care patients with documented moderate or severe pain, analgesia has not historically been prescribed in as many as 25% of patients. This failure to address anal- gesic needs in adult patients is typically worse for pediatric patients with as many as 40% of children not receiving analgesic therapy for acute musculoskeleta l injuries. These findings have been replicated in many studies and indicate that analgesics are not routinely prescribed to patients with orthopedic injuries, even if they describe their pain as moderate to severe. In order to optimize analgesia for patients in all populations, it is essential for the medical provider to routinely identify, document, and treat the pain associated with injuries, particularly acute musculoskeletal injuries. CLINICAL ASSESSMENT The assessment of acute musculoskeletal injuries is generally straightforward. Unlike pain secondary to a medical event, the pain of orthopedic trauma can usu- ally be readily identified. Assessment of the injury may include the use of clinical decision rules, such as the Ottawa ankle or knee rules, ancillary studies such as plain radiographs or more advanced radiography, but should always include a careful neur ological exam. The practitioner should consider compartment syndrome in any case where pain seems to be out of proportion to the exam, as well as in injuries with high-risk mechanisms, such as crush injuries, and in cases where neurologic impairment appears to be present. All patients should be clinically reassessed after any procedure or splinting. PAIN CONSIDERATIONS The pain associated with musculoskeletal injuries can be severe. The best route to achieving analgesia in these patients is a matter of some debate. It is clear, however, that patients are more satisfied when their pain is addressed in the initial clinical encounter. An approach to this concept in the outpatient setting is to integrate a ‘‘starter pack’’ strategy for medications 141 to be dispensed in the acute care setting to allow for immediate analgesic therapy (Figure 22-1). This concept was validated in the ED population by McIntosh and Leffler. In their study of patients with acute pain, 92% of patients stated that they achieved adequate pain relief when a five-tablet acetaminophen/oxycodone starter pack was dispensed vs only 77% in a group that received written prescriptions. Drendal et al. have noted pain scales in pediatric patients with isolated extremity fractures to be highest at the time of injury. These high pain scores appear to remain elevated for the first 48 hr postinjury. Functional limitations, such as decreased eating and sleeping, typically improve after 2 days, with analgesic use noted as highest during the first 3 days following injury. These findings suggest that the most important time period in affecting pain associated with acute musculo- skeletal injuries is at the time of the clinical encounter and following 48–72 hr. The economic impact of liberally pre- scribing ‘‘starter packs’’ has not been studied. This practice has been demonstrated to increase patient satisfaction. The most appropriate analgesic for musculoskeletal injuries is unclear. The ‘‘perfect’’ medication does not exist and each patient must be approached individually (Table 22-1). The categories of medications are most simply broken down into narcotic-containing vs non- narcotic-containing analgesics. The decision to use narcotic analgesics should always be left to the di scretion of the provider, as the published medical literature does not offer much guidance as to appropriate patient selection in cases where there is no objective findings to substantiate pain from an orthopedic injury. The analgesic potency of narcotic-containing medi- cations is well known. However, their side effects are myriad and include sedation, a decrease in REM sleep, decreased gastrointestinal motility, and urinary reten- tion. Combination nonsteroidal anti-inflammatory drug (NSAID) or other nonnarcotic and narcotic therapy is known as mu ltimodal or ‘‘balanced’’ analgesia. The benefits of this approach are well documented in the surgical literature: side effects associated with narcotics are minimized whereas that of analgesia are enhanced. Balanced analgesia employs different drugs in a com- plementary fashion to target different points in the afferent and efferent pain pathway. These narcotic-sparing regi- mens have been shown to decrease narcotic usage and side effects af ter minor surgeriesand wo uld likely b e similarly efficacious in the outpatient orthopedic patient. PAIN MANAGEMENT The approach to the outpatient treatment of the painful musculoskeletal injury should take into account the degree of the patie nt’s pain and the potential side effects of the various analgesic possibilities (Table 22-1). Once the decision to treat with analgesics has been made, there is little data guiding the choice of analgesic. There Opiods required? No: NSAIDs or APAP (1) Yes: Age? Adult: Starter pack (2) Balanced analgesia (3) Duration based on injury and follow-up care plan Pediatric: Starter pack Balanced analgesia 72 hr duration Figure 22-1. Algorithm for outpatient pain management for the patient with acute musculoskeletal injury. Legend 1) NSAIDS and Acetaminophen (APAP) have been shown to be equally as efficacious in acute musculoskeletal injuries. 2) Starter packs, both NSAID and narcotic based, have been shown to decrease outpatient pain scales and increase patient satisfaction. 3) The appropriate balanced analgesia regimen in this setting is a combination opiod and non-opiod therapy. This reduces both the amount of narcotic utilized and associated side effects. 142 Analgesia for the Emergency Patient has been some suggestion that NSAIDs should be avoided during the healing phase of bony injuries. Theoretically, NSAIDs may cause a delay in fracture healing and this has been supported in animal research. Cyclooxygenase-2 (COX-2) has been found to be essential to bone repair in mice: genetically manipulated mice that produce no COX-2 show reduced bone for- mation and a higher likelihood of nonunion 21 days postfracture. The in vivo effects of endogenous COX-1 and COX-2 inhibition have not been consistently char- acterized. In humans the data is less clear. There have been retrospective case reports and reviews on the sub- ject, but relatively few compelling trials. In a review of nine studies assessing the clinical effects of NSAIDs on bone healing, only two were found to be randomized, controlled clinical trials. The retrospective reviews in this series were hampered by methodological shortcomings with inconsistent findings. O f the two prospective trials, one showed no evidence to suggest that prioxicam affected fracture healing with the other finding that rofecoxib and celecoxib had no detrimental affects. It is unclear how these results translate to the acute fracture patient. Currently, there is no evidence-based contraindica- tion to the use of NSAIDs in fracture patients. The benefits of NSAID analgesia must be weighed against these theoretical concerns. A balanced clinical approach may be to prescribe fewer NSAIDs in patient popula- tions with wound healing concerns, such as diabetics or scaphoid fractures, and continue to use NSAIDS as a narcotic-sparing agent in healthy patients. Tramadol is a nonnarcotic agent that has been con- sidered for the acute management of pain in the ortho- pedic patient. However, the analgesic properties of tramadol for the acutely injured patient appear to offer little benefit compared to NSAID agents, at the same time having a substantially increased price and an increased incidence of side effects such as nausea, con- stipation, and a risk of seizures. There is no consensus within the literature favor- ing any one nonnarcotic analgesic regimen. For most orthopedic patients, NSAID therapy should be used as Table 22-1. Available agents, methods of administration, complications, and other considerations in the analgesic approach for outpatient management of patients with acute musculoskeletal injuries Analgesics Dose Comments Nonopiate therapy Acetaminophen Pediatric: 15–20 mg/kg q 4 hr Minimal side effects Adult: 500–1,000 mg q 4 hr Ibuprofen Pediatric: 10 mg/kg PO May be combined with APAP; Adult: 600–800 mg q 6–8 hr Risk of side effects, particularly gastrointestinal irritation and bleeding should be considered with increasing patient age, NSAID dose, and duration of therapy elevating risk Tramadol Adult: 50–100 mg q 6 hr Do not use with SSRI agents; common side effects are nausea and constipation; no significant benefit compared to NSAID therapy Opiate therapy a Codeine Pediatric: 0.5–1 mg/kg q 6 hr Poorly tolerated in adults owing to high incidence nausea, vomiting, and rashAge 6–12: 5–15 mg q 6 hr Adult: 15–60 mg q 6 hr Propoxyphene Adult: 50–100 mg q 4 hr Used in APAP and NSAID combinations; no significant analgesic efficacy compared to NSAIDs Hydrocodone Adult: 5–10 mg q 6 hr Used in APAP and NSAID combinations Oxycodone Adult: 5–20 mg q 6 hr Used in APAP and NSAID combinations; higher doses utilized in delayed release preparation (e.g., Oxycontin); also available without APAP and NSAID Notes: APAP, acetaminophen; SSRI, selective serotonin reuptake inhibitors; NSAIDs, nonsteroidal anti-inflammatory drugs. a Common side effects of all opiates include nausea, vomiting, somnolence, and constipation. Analgesia in Acute Musculoskeletal Injury 143 part of a multimodal, narcotic-sparing regimen with liberal use of narcotic agent s during the initial injury and healing period for pain that exceed s NSAID anal- gesia approaches. Opiate analgesic agents are available in a wide variety of treatment strategies including sustained release pre- parations and opiate combinations with NSAIDs and acetaminophen. The selection of an agent should be guided by the patient age, injury, and previous utiliza- tion of narcotic agents. A simple approach to selection of a narcotic should include the patient’s previous his- tory of agents that the patient has tolerated, or con- versely agents that have been poorly tolerated, to guide selection of an opiate agent that will have minimal side effects for the patient. All patients should be informed of the common side effects of nausea, vomiting, somno- lence, and constipation. A regimen to enhance gastro- intestinal motility should be routinely recommended, particularly to older patients. The duration of outpatient analgesia should be dictated by the patient’s injury and individual patient needs. Most pediatric patients do not require analgesics beyond 48–72 hr. However, optimal analgesic duration of therapy has not been adequately studied in acute musculoskeletal injury populations. Most acute care providers choose to prescribe analgesia for a period of time consistent with the specific injury and to bridge patient management between the initial encounter and follow-up care. FOLLOW-UP CONSIDERAT IONS Patients should obtain follow-up as requisite for their individual musculoskeletal injury. This may include fol- low-up with an orthopedic surgeon, a primary care physician, or both. Patients should be instructed to return for worsening pain as this may be secondary to the de- velopment of compartment syndrome or to iatrogenic causes such as a restrictive dressing, splint, or cast. SUMMARY The choice of an analgesic regimen for the musculoskel- etal injury patient should be individualized by the care provider to the patient and his or her specific injury. In patients with less severe pain, acetaminophen has been shown to be as efficacious as oral NSAID therapy. Patients who have more painful injuries should have NSAID or acetaminophen therapy supplemented by opiate analgesics as a balanced analgesic plan. This approach has been shown to decrease narcotic utiliza- tion and common narcotic therapy side effects. Once the decision to provide outpatient analgesia has been made, patient satisfaction and pain scores are significantly improved when a short course of medica- tions are dispensed at the time of the initial patient encounter. BIBLIOGRAPHY 1. Brown JC, Klein EJ, Johnston BD, Cummings PC. Emergency department analgesia for fracture pain. Ann Emerg Med 2003;42(2):197–205. 2. Comprehensive accreditation handbook for hospitals: The official handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2001. 3. Petrack EM, Christopher NC, Kriwinsky J. Pain manage- ment in the emergency department: Patterns of analgesic utilization. Pediatrics 1997;99:711–714. 4. Wilson JE. Oligoanalgesia in the emergency department. Am J Emerg Med 1989;7; 620–623. 5. Mcintosh SE, Leffler S. Pain management after discharge from the ED. Am J Emerg Med 2004;22(2):98–100. 6. Drendel AL. Outpatient pediatric pain m anagement prac- tices for fractures. Pediatr Emerg Care 2006;22(2):94–99. 7. Gimbel JS. Efficacy and tolerability of Celecoxib versus Hydrocodone/Acetaminophen in the treatment of pain after ambulatory orthopedic surgery in adults. Clin Ther 2001;23(2):228–241. 8. Cohen MJ. Schecter WP. Perioperative pain control: A strategy for management. Surg Clin North Am 2005;85:1243– 1257. 9. Huang N, Cunningham F, Laurito CE, Chen C. Can we do better with postoperative pain management? Am J Surg 2001;182(5):440–448. 10. Kehlet H. Balanced analgesia prerequisite for optimal recovery. Br J Surg 1998;85:3–4. 11. Woo WK, Man S, Lam P, Rainer TH. Randomized double-blind trial comparing oral paracetamol and oral nonsteroidal antiinflammatory drugs for treating pain after musculoskeletal injury. Ann Emerg Med 2005;46(4):352–361. 12. Rawal N. Postoperative analgesia at home after ambulatory hand surgery: A controlled comparison of Tramadol, Metamizol and Paracetamol. Anesth Analg 2001;92 (2):347–351. 13. Adolphson P, Abbaszadegan H, Jonsson U, et al. No effect of Piroxicam on osteopenia and recovery after 144 Analgesia for the Emergency Patient Colles’s fracture: A randomized, double blind, placebo controlled trial. Arch Orthop Trauma Surg 1993;112: 127–130. 14. Zhang X, Schwarz EM, Young, DA, et al. Cyclooxygenase2 regulates mesenchymal cell differentiation into osteoblast lineage and is critically involved in bone repair. J Clin Invest 2002;109:1405–1415. 15. Drendel AL, Brousseau DC, Gorelick MH. Outpatient pediatric pain management practices for fractures. Pediatr Emerg Care 2006;22:94–99. Analgesia in Acute Musculoskeletal Injury 145 SECTION THREE. PROCEDURAL SEDATION FOR THE EMERGENCY PATIENT 23 Patient Assessment and Preprocedure Considerations Baruch Krauss and Steven M. Green SCOPE OF THE PROBLEM CLINICAL ASSESSMENT Management Options SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM Procedural sedation and analgesia (PSA) has three essential components: the initial presedation assessment, sedation during the procedure, and postprocedure recovery and discharge from the ED. The most important initial step is togather sufficient information to make an informed risk-benefit analysis. If the risks of sedation outweigh the benefits and the procedure is nonemergent, then the procedure should be postponed or managed in a more controlled environment of an operating room. If the procedure is emergent or the situation is life threat- ening, then the procedure should be undertaken with recognition of the critical nature of intervention. The risks, benefits, and limitations of PSA should be discussed with the patient (or their parent or guardian) in advance and verbal agreement obtained. Written consent is not required (unless a local institutional requirement), though documentation of this process should be routine whether a verbal or written consent is obtained. PSA enhances patient cooperation and facilitates the successful completion of diagnostic or therapeutic pro- cedures that cause stress and pain. Anxiety alleviation and amnesia are additional benefits particularly impor- tant for children, who may perceive even simple pro- cedures as terrifying. There are many factors that influence the decision- making process surrounding PSA, especially in children, and include age and temperament of the patient, type of procedure, amount of pain involved, movement control required, and patient/parental anxiety level (Figure 23-1). For children, a nonthreatening, age-appropriate approach, distraction techniques, and guided imagery may help direct the patient’s attention away from the anxiety and pain associated with the procedure. Telling young children too much information about a procedure may elevate their anxiety level and should be avoided whenever possible. Nonpharmacologic interventions, combined with topical and/or local anesthetic, may obviate or greatly reduce the need for systemic sedation. CLINICAL ASSESSMENT A directed history and physical examination should precede patient sedation and if this evaluation suggests additional risk, the advisability of sedation should be reconsidered (Figures 23-1 and 23-2). Physicians should assess the type and severity of any underlying medica l problems. A common tool used for this purpose is the American Society of Anesthesiologists’ (ASA) physical status classification that is used for preoperative risk strat- ification (Table 23-1). Current medications and allergies should be verified. It is advisable to inquire regarding prior adverse experiences with PSA or anesthesia. For emergent sedations, the AMPLE (Allergies, Medications, Past medical problems , Last meal, Events) format is sufficient. The physical examination should be directed at identifying patients with a potentially diffi- cult airway or risk for cardiorespiratory instability. The 147 airway should be inspected to determine if there are abnormalities that might impair airway management including morbid obesity, short neck, micrognathia, large tongue, trismus, tracheomalacia, laryngomalacia, history of difficult intubation, congenital anomalies of the airway and neck, and obstructive sleep apnea. The physical examination should include evaluation of neck mobility, mouth opening, dentition, and size of the tongue and mandible. The Mallampati classification is a well-es tablished method for estimating a potentially difficult airway based on the extent of visibility of pha- ryngeal landmarks. If the tonsilar pillars and uvula cannot be visualized (Mallampati Class IV), the patient may be difficult to ventilate and intubate. The heart and lungs should be auscultated for equal normal ventilation, normal heart sounds, and rhythm. The degree of reserve of patients with known cardio- vascular disease should be evaluated, as most sedation agents can cause vasodilatation and hypotension. Lung auscultation should be performed to assess for active pulmonary disease, especially obstructive lung disease and active upper respiratory infections that may predispose the patient to heightened airway reactivity. Baseline mental status must be evaluated and docu- mented, and hydration status should be assessed. The implications of delayed metabolism or excretion of PSA agents in infants less than 6 months of age, in the elderly, and in the presence of hepatic or renal abnormality should be carefully considered. Presedation laboratory testing should be guided by the clinical scenario; ‘‘routine’’ tests seldom, if ever, will change the sedation plan. Conditions such as active airway infections, dehydration, or fever may increase the risk of complications and should lead to postponement of elective sedations and appropriate management prior to emergent sedations (enhanced monitoring, reduced Motion control Analaysis Sedation Analgesia Amnesia Operating room Postpone procedure Perform procedure Benefit>>Risk Risk>>Benefit Risk-benefit analysis Personnel/equipment availability Time of day (infants/toddlers) Previous experience Anxiety level Age and cooperation level Awake+active Naptime Bedtime Positive/neutral Negative High Low Noncooperative Infant Variably cooperative Toddler Cooperative School age and above Perform procedure Healthy (Class 1–2) Risk-benefit analysis Figure 3 URI Comorbidity (Class 3–5) Perform procedure Operating room ASA class Fasting state Airway reactivity Medication reactions Active asthma (Morphine, meperidine) histamine Rx (ketamine) emergence Rx (Benzodiazepines, barbiturates) paradoxical Rx Goals Type Nonpainful Sedation endpoint Monitoring Minimally painful Painful Mild sedation Moderate sedation Dissoclative sedation Deep sedation General anethesia Mild, moderate sedation Deep, dissociative sedation Patient-related factors Procedural factors Patient > Procedure Figure 23-1. Factors determining medication choice and sedation endpoint. 148 Procedural Sedation for the Emergency Patient level of sedation, avoidance of agents that hypersensitize the laryngeal reflexes [i.e., ketamine], and use of reversible intravenous agents). In an ongoing effort to optimi ze patient safety during PSA, patients are typically queried regarding the timing and nature of recent oral intake. This information is used to estimate the risk of pulmonary aspiration and to plan sedation depth and timing accordingly. Emergency physicians have historically had no specific guidelines to inform their clinical decision making with Step 1 Assess patient risk • Potential for difficult airway (short neck, micrognathia, large tongue, tracheomalacia, laryngomalacia, history of difficult intubation, congenital anomalies of the airway and neck, sleep apnea) • Conditions predisposing to esophageal reflux (elevated intracranial pressure, esophageal disease, hiatal hernia, peptic ulcer disease, gastritis, bowel obstruction, ileus, tracheo-esophageal fistula) • Extremes of age (>70 years or <6 months) • ASA physical status 3 or greater (Table 23.1) • Other clinical findings leading the EP to judge the patient to be at higher than standard risk (e.g., altered level of consciousness, frail appearance) Standard vs higher risk Step 2a Assess the timing and nature of recent oral intake Step 2b Assess the urgency of the procedure • Nothing • Clear liquids only • Light snack • Heavier snack or meal • Emergent (cardioversion for life-threatening dysrhythmia, reduction of fracture or dislocation with vascular compromise, intractable pain or suffering) • Urgent (care of dirty wounds and lacerations, animal and human bites, abscess incision and drainage, fracture reduction, hip reduction, lumbar puncture for suspected meningitis, arthrocentesis, neuroimaging for trauma) • Semi-urgent (care of clean wounds and lacerations, shoulder reduction, neuroimaging for new-onset seizure, foreign body removal, sexual assault examination) • Nonurgent or elective (nonvegetable foreign body in external auditory canal, chronic embedded soft tissue foreign body, ingrown toenail) Step 4 Determine sedation level and length • Minimal sedation (anxiolysis) • Dissociative sedation; brief or intermediate- length moderate sedation • Extended moderate sedation • Brief deep sedation • Intermediate or extended deep sedation Brief: <10 min Intermediate: 10–20 min Extended: >20 min Operating room Postpone procedure Sedate Figure 23.1 Step 3 Risk-benefit analysis Risks > benefits Benefits > risks Figure 23-2. Preprocedural checklist. Patient Assessment and Considerations 149 [...]... levels of sedation All levels of sedation All levels of sedation All levels of sedation Clear liquids All levels of All levels of sedation only sedation Up to and including brief deep sedation Up to and including extended moderate sedation Up to and including Up to and including sedation Light snack All levels of brief deep sedation dissociative sedation; Minimal sedation nonextended only moderate sedation. .. sedation Up to and including All levels of Up to and including sedation brief deep sedation extended moderate Minimal sedation only sedation Light snack Up to and including All levels of dissociative sedation; sedation nonextended Minimal sedation Minimal sedation only only Up to and including Minimal sedation or meal sedation only only Dissociative sedation; brief or intermediate-length moderate sedation. .. prolongation of pain and anxiety for the patient and the inconvenience for them and their BIBLIOGRAPHY 1 Krauss B, Green SM Procedural sedation and analgesia in children Lancet 20 06; 367 : 766 –780 2 Green SM, Roback MG, Miner JR, Burton JH, Krauss B Fasting and emergency department procedural sedation and analgesia: A consensus-based clinical practice advisory Ann Emerg Med 2007;49:454– 461 3 Green SM,... or meal sedation Up to and including extended moderate Minimal sedation Minimal sedation only only sedation High-risk patient Procedural urgency Oral intake in the prior 3 hr Emergent Urgent Semi- Non- procedure procedure urgent urgent Nothing All levels of Intermediate or extended-length deep sedation All levels of sedation All levels of sedation All levels of sedation Minimal sedation only sedation. .. practice guideline for emergency department ketamine dissociative sedation in children Ann Emerg Med 2004;44: 460 –472 4 Agrawal D, Manzi S, Gupta R, Krauss B NPO status and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department Ann Emerg Med 2003;42 :63 6 64 6 5 Green SM, Krauss B Pulmonary aspiration risk during ED procedural sedation – an examination... CLINICAL ASSESSMENT SEDATION AND PAIN CONSIDERATIONS SEDATION AND PAIN MANAGEMENT FOLLOW-UP CONSIDERATIONS SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM In 2002 over 2.4 million children with lacerations were seen in emergency departments (ED) across the United States Children have many characteristics that can make proper wound management and laceration repair challenging Young age and anxiety preclude... agents used in 10 pediatric sedation and analgesia in the emergency department Ann Emerg Med 2004;44:342–377 Krauss B, Green SM Procedural sedation and analgesia in children Lancet 20 06; 367 : 766 –780 Mancuso C, Tanzi MG, Gabay M., Paradoxical reactions to benzodiazepines: Literature review and treatment options Pharmacotherapy 2004;24(9):1177–1185 Barnett P Propofol for pediatric sedation Pediatr Emerg Care... Propofol (Diprivan) Ketamine (Ketalar) 10–15 mg/kg 6 10 mg/kg 6 mg/kg Recommended dosage Medication 30 60 s min PR:15 60 min Onset 5–20 min 15–30 min 15–30 min 15–30 min IM PR PO Intra-nasal 1–3 min 1–2 min IV IV IV IV over period of 3 0 -6 0 1 min seconds IV sedation IV rate should be . Rx Goals Type Nonpainful Sedation endpoint Monitoring Minimally painful Painful Mild sedation Moderate sedation Dissoclative sedation Deep sedation General anethesia Mild, moderate sedation Deep,. undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003;42 :63 6 64 6. 5. Green SM, Krauss B. Pulmonary aspiration risk during ED procedural sedation – an examination. Determine sedation level and length • Minimal sedation (anxiolysis) • Dissociative sedation; brief or intermediate- length moderate sedation • Extended moderate sedation • Brief deep sedation