EMERGENCY SEDATION AND PAIN MANAGEMENT - PART 7 pptx

complications for pediatric fracture reduction than ketamine/midazolam. Ketamine and ketamine/midazolam, administered IV or IM, have been shown to provide safe, effective procedural sedation and analgesia for pediatric lacera- tion repair. As mentioned above, ketamine/midazolam provides better pain control and anxiety relief with less respiratory complications than midazolam/fentanyl. However, when ketamine is used, vomiting is more common, and emergence reactions (mostly mild) will occur, regardless of the addition of midazolam. In a randomized, controlled trial comparing IV to IM keta- mine for fracture reduction, IM ketamine provided more efficacious sedation but resulted in more frequent vomiting and longer lengths of sedation. The shorter acting agents propofol and etomidate have been used for ED pediatric procedures such as orthopedic reductions. The properties of sedation, amnesia, and rapid recovery time make these drugs attractive for ED use. However, the short duration of action limits their use for pediatric laceration repair. Sedation with 50% nitrous oxide effectively decreases patient distress and is associated with a low rate of adverse events in children receiving laceration repair. The use of nitrous oxide is limited by the need for special delivery and gas scavenger equipment and patient compliance with holding the face mask in place to facilitate delivery of the drug. FOLLOW-UP CONSIDERATIONS Although delayed adverse events associated with pediatric procedural sedation have been described, significant adverse events, such as apnea or oxygen desaturations, are unlikely to occur greater than 30 min after the last sedation drug administration. On discharge from the ED, advise parents and children about other adverse events that they may still experience (i.e., vomiting, dizziness, emergence reactions), instruct them about proper wound care, and direct them to appropriate follow-up care. SUMMARY When determining how best to control pain and patient movement in children with lacerations, consider patient age and development, the presence of underlying conditions, and the location and extent of the laceration. Recognize that nonpharmacologic techniques may be used effectively to avoid the use of procedural sedation. Choose sedation drugs to fit the desired depth of seda- tion and estimate length of time need ed to perform the repair. Recognize that the properties of sedation drugs differ, and combinations may be required to provide sedation, analgesia, and amnesia of the event. Finally, it is essential to enlist the input of parents or guardians in the decisions regarding the care of their children. BIBLIOGRAPHY 1. Singer AJ, Thode HC, Hollandaer JE. National trends in ED lacerations between 1992 and 2002. Am J Emerg Med 2006;24:183–188. 2. Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: A comparison of common parenteral drugs. Acad Emerg Med 2005;12:508–513. 3. Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency depart- ment: Safety profile in 1,022 cases. Ann Emerg Med 1998;31(6):688–697. 4. Lawrence LM, Wright SW. Sedation of pediatric patients for minor laceration repair: Effect on length of emergency department stay and patient charges. Pediatr Emerg Care 1998;14:393–395. 5. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006;367:766–780. 6. Loryman B, Davies F, Chavada G. Consigning ‘‘bruta- caine’’ to history: A survey of pharmacological techniques to facilitate painful procedures in children in emergency departments in the UK. Emerg Med J 2006;23:838–840. 7. Sinha M, Christopher NC, Fenn R, et al. Evaluation of nonpharmacologic methods of pain and anxiety manage- ment for laceration repair in the pediatric emergency department. Pediatrics 2006;117:1162–1168. 8. Hawk W, Crockett RK, Ochsenschlager DW. Conscious sedation of the pediatric patient for suturing: A survey. Pediatr Emerg Care 1990;6:84–88. 9. Brown ET, Corbett SW, Green SM. Iatrogenic cardiopul- monary arrest during pediatric sedation with meperidine, promethazine, and chlorpromazine. Pediatr Emerg Care 2001;17:351–353. 10. Mace SE, Barata IA, Cravero JP, et al. Clinical policy: Evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency depart- ment. Ann Emerg Med 2004;44:342–377. 11. Everitt IJ, Barnett P. Comparison of two benzodiazepines used for sedation of children undergoing suturing of a laceration in an emergency department. Pediatr Emerg Care 2002;18:72–74. 12. Theroux MC, West DW, Corddry DH, et al. Efficacy of intranasal midazolam in facilitating suturing of lacerations Sedation for Pediatric Laceration Repair 171 in preschool children in the emergency department. Pediatrics 1993;91:624–627. 13. McGlone R, Fleet T, Durham S, et al. A comparison of intramuscular ketamine with high dose intramuscular midazolam with and without intranasal flumazenil in children before suturing. Emerg Med J 2001;18:34–38. 14. Younge PA, Kendall JM. Sedation for children requiring wound repair: A randomised controlled double blind comparison of oral midazolam and oral ketamine. Emerg Med J 2001;18:30–33. 15. Kanegaye JT, Favela JL, Acosta M, et al. High-dose rectal midazolam for pediatric procedures: A randomized trial of sedative efficacy and agitation. Pediatr Emerg Care 2003;19:329–336. 16. Kennedy RM, Porter FL, Miller JP, et al. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics 1998; 102:956–963. 17. Wathen JE, Roback MG, MacKenzie T, Bothner JP. Does midazolam alter the clinical effects of intravenous keta- mine sedation in children? A double-blind, randomized, controlled emergency department trail. Ann Emerg Med 2000;36:579–588. 18. Roback MG, Wathen JE, MacKenzie T, et al. A random- ized, controlled trial of IV versus IM ketamine for sedation of pediatric patients receiving emergency department orthopedic procedures. Ann Emerg Med 2006;48: 605–612. 19. Luhmann JD, Kennedy RM, Porter FL, et al. A randomized clinical trial of continuous flow nitrous oxide and midazolam for sedation of young children during lacera- tion repair. Ann Emerg Med 2001;137:20–27. 172 Procedural Sedation for the Emergency Patient 27 Procedural Sedation for Pediatric Radiographic Imaging Studies Nathan Mick SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN/SEDATION CONSIDERATIONS PAIN/SEDATION MANAGEMENT Sedative-Hypnotic Agents Chloral hydrate Benzodiazepines Barbiturates Propofol Etomidate Ketamine FOLLOW-UP CONSIDERATIONS SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM In virtually all areas of medicine, including pediatrics, the use of advanced diagnostic imaging has increased sub- stantially. Although utilization of all imaging modalities has increased, the use of computed tomography (CT) has grown at a particularly brisk rate, specifically in the evalu- ation and management of the trauma patient. These increases have implications for physicians in the emergency department (ED) as procedural sedation is frequently required to calm and immobilize a child for these studies. It may be possible to perform many pro- cedures utilizing behavioral or distraction techniques, obviating the need for procedural sedation. However, the stressful, frightening nature of an injury or ED environ- ment often requires moderate to deep sedation to over- come these factors and achieve diagnostic imaging goals. CLINICAL ASSESSMENT Prior to the administration of any sedative agent, a careful preprocedure assessm ent should be undertaken. Special attention should be given to historical features that may complicate procedural sedation including a past history of adverse events with sedation or anes- thesia, medication history, and medication allergies. The history should also evaluate the patient for seizure potential and/or the likelihood of a neurological injury/ condition that may result in elevated intracranial pres- sures, as these considerations will be of importance in the consideration for the appropriateness of ketamine. The guidelines of the American Society of Anesthe- siology recommend delaying sedation for at least 2–3 hr after the last clear liquids and 4–8 hr after solids or milk. These recommendations are often not feasible when applied to the ED and there is a growing body of liter- ature that shorter fasting times are not associated with adverse events during procedural sedation. A thorough examination of the airway should be performed in every patient prior to sedation with par- ticular attention given to predictors of difficult airway management including congenital airway anomalies (i.e., the Pierre-Robin sequence or Beckwith-Wiedemann syndromes) or acquired conditions (i.e., obesity, trauma, 173 or retropharyngeal abscess) that may make endotracheal intubation or ventilation problematic. The presence of a difficult airway should alert the clinician that the proce- dure may be better suited to the more controlled envi- ronment of the operating room, rather than the ED. Auscultation of the lungs should be performed as the presence of active upper respiratory infection or asthma increases the risk of laryngospasm by as much as fivefold. A thorough cardiovascular examination should occur in every patient, particularly in patients with known underlying heart disease. Volume status assessment is imperative in all children, especially those with cardiac disease as most of the agents used for sedation, with the exception of ketamine, result in vasodilatation and carry the risk of hypotension in the hypovolemic child. Minimal monitoring requirements include pulse oximetry, cardiac monitor, and blood pressure assess- ment. Airway resuscitation equipment such as bag-valve mask, suction, and tools for endotracheal intubation should be readily available. Reversal agents, such as naloxone and flumazenil, should be on hand if opiates or benzodiazepines are being employed. End-tidal car- bon dioxide measurements using capnography may alert the clinician to apnea and hypoventilation prior to a drop in oxygen saturati on and this monitoring tech- nique is being adopted in many institutions. PAIN/SEDATION CONSIDERATIONS There are several very important considerations that impact the planning of procedural sedation for pediatric diagnostic imaging procedures (Table 27-1). These include age of the pati ent, the specific imaging proce- dure that is planned, whether intravenous contrast is going to be used, and whether there is going to be any pain associated with the procedure (i.e., hip aspiration during ultrasonography or contrast injection during VCUG) (Figure 27-1). Age of the patient greatly impacts the procedural sedation strategy as older children may require only anxiolysis whereas younger children are more likely to require deeper levels of sedation. The time of day also plays a role as a child that is tired around naptime or at night may only require a feeding and be allowed to sleep naturally rather than undergo sedation for a study such as CT of the head. The type of imaging study is also a factor in the choice of any sedation strategy. Obtaining plain radiographs or performing an ultrasound rarely requires sedation. In contrast, magnetic resonance imaging because of the length of the procedu re, the noise involved, and the inability to visualize and assess the patient on an ongoing basis, may require general anesthesia or even endotracheal intubation. Children younger than 3 months of age typically can be bundled and imaged without sedation whereas it may not be possible to achieve the required degree of immo- bility for imaging in older infants and toddlers without moderate to deep sedation. Sedation is often required in younger, uncooperative children, particularly if intra- venous contrast is being used. Contrast studies take longer to perform and the timing of the bolus is critical to the acquisition of interpretable images. Thus, in studies involving coordination or precision of timing, sedation may be needed as the study cannot be ‘‘redone’’ if there is significant patient movement. Some pediatric radiographic studies are coupled with diagnostic procedures such as ultrasonography and hip aspiration for the evaluation of possible septic arthritis or fluoroscopic-guided lumbar puncture. For these types of procedures, it is imperative to choose a sedative agent with analgesic properties (Table 27-2). PAIN/SEDATION MANAGEMENT There are a variety of agents available and suitable for procedural sedation for pediatric imaging studies Table 27-1. Factors to consider for procedural sedation during pediatric radiographic procedures  Age of patient  Time of day (near sleep or naptime)  Duration of procedure  Degree of cooperation or immobility required  Presence of head injury or risk of elevating intracranial pressures  Hemodynamic stability  Need for analgesia  Provider training and experience 174 Procedural Sedation for the Emergency Patient Sedative-Hypnotic Agents Chloral hydrate Chloral hydrate is a pure sedative agent without analgesic properties that has been extensively used for procedural sedation, particularly for outpatient diagnostic imaging in children under the age of 3 years. Chloral hydrate has an excellent safety profile and can be given either orally or rectally at a dose of 25–100 mg/kg. The choice of a proper dose for choral hydrate administration should be adapted to the clinical scenario as higher doses (75–100 mg/kg) will result in higher rates of effective sedation when simultaneously prolonging the sedation period. Advantages to chloral hydrate include predictable clinical effects and the fact that intravenous access is not required for administration. Disadvantages include a dose-dependent, prolonged duration of action (60–180 min). There have been selected reports of prolonged after effects associated with chloral hydrate, including behavioral changes that may last 24 hr. Benzodiazepines Midazolam is the benzodiazepine of choice for short procedures as it provides sedation, anxiolysis, and amnesia at appropriate doses. Midazolam can be give through a variety of routes including orally (0.2–0.5 mg/ kg) and intravenously (0.1 mg/kg). Midazolam is often used in combination with a short-acting opioid such as fentanyl. Combination use is associated with higher rates of respiratory depression and adverse hemodynamic events, though reversal of sedation with flumazenil is possible. Some children experience a paradoxical excitatory response to midazolam. This response can be difficult to treat as the child will be noted to increase in agitation and anxiousness with midazolam dosing. Parents should be warned beforehand of the potential of this effect as it can be a frustrating experience that may have to be countered with higher dosing and/or change to another sedation agent depending upon the clinical circum- stances. Barbiturates Barbiturates, particularly pentobarbital, have been safely used for sedation during diagnostic procedures for many years. The advantages of barbiturates include a rapid onset and brief duration of clinical effects as well as dose- and route-dependent potent sedative effects. Ide- ally, these agents are titrated to effect intravenously though a variety of administration routes exist including the rectal route . Rectal administration of methohexital and thiopental has been described in a number of investigations in the medical literature. These reports have characterized this route as efficacious and safe, with a reduced rate of respiratory depression when compared to intravenous administration. Administration through the rectal route is complicated by defecation in as many as one-quarter of the patients, as a consequence of the irritant effect to the mucosa. This effect can be reduced by drug dilution with saline, and a consequent large increase in volume instilled. Pentobarbital is a vessel irritant and will often burn during intravenous administration. This effect can be attenuated by dilution with normal saline. Dose- dependent respiratory depression and hypotension can be observed. Careful titration, particularly in volume- depleted children, is an important consideration. Propofol Propofol is increasingly utilized outside the operating room environment for sedation for all manner of procedures, including diagnostic imaging. Propofol is a powerful sedative hypnotic with characteristics similar to barbiturates. Propofol is administered intravenously at an initial dose of 1 mg/kg followed by 0.5 mg/kg to maintain the sedated state. The extremely short duration of action and rapid onset make propofol an ideal agent for b rief procedures. Its rapid metabolism and distribution may require higher dosing i n younger patients, approximating 2.0–2.5 mg/kg, to achieve the depth of sedation often required for imaging studies. Disadvantages to propofol use include pain at the injection site and respiratory depression. Children should be monitored closely for adequate ventilation throughout propofol sedation. Monitoring during pro- pofol sedation should be done by a caregiver skilled in emergent rescue interventions. The formulation of propofol also con tains egg proteins and a history of egg allergy is considered a contraindication to its use. 176 Procedural Sedation for the Emergency Patient Etomidate Etomidate is an imidazole, amnestic agent with rapid onset and brief duration of action. It has been widely used as an induction agent for rapid sequence intuba- tion and only recently has begun to be used for proce- dural sedation. Advantages to etomidate include its stable hemodynamic profile and cerebroprotective properties. Adverse events associated with etomidate use include respiratory depression, myoclonus, and vomit- ing. Dosages for procedural sedation range from 0.1 to 0.2 mg/kg IV with a duration of action of 8–10 min. Myoclonus is perhaps the most significant, and unusual, disadvantage to the use of etomidate occurring in approxi- mately 20% of patients. Series of children sedated with etomidate for radiographic imaging have been few to date. Ketamine Ketamine is a unique agent that induces a dissociative state characterized by maintenance of protective airway reflexes. It is associated with complete amnesia and analgesia. Ketamine can be give intravenously (1 mg/kg followed by 0.5 mg/kg for maintenance) and intramus- cularly (4–5 mg/kg IM) and has the advantage of a stable hemodynamic profile, even in hypovol emic patients. Disadvantages to the use of ketamine include an in- creased risk of laryngospasm in children with active upper resp iratory infections or asthma and a small risk of emergence reaction. Emergence reactions in children sedated with ketamine tend to be relatively mild and short acting. Ketamine also causes an increase in intra- cranial pressure, making it ill-suited for many patients undergoing diagnostic imaging for head injury or with a significant seizure history. FOLLOW-UP CONSIDERATIONS All children undergoing procedural sedation for diag- nostic imaging should be monitored for respiratory depression. At discharge, the child should be awake, alert, and at an age-appropriate baseline level of neu- rologic function and should be accompanied by a parent or guardian. Sedation-specific discharge instructions including possible complications and signs of respiratory depres- sion should be given to each patient, as some sedation agents may have a prolonged duration of action. SUMMARY Sedation of children for radiographic imaging studies is a common practice in many clinical environments. Pediatric imaging evaluations may require sedation, particularly longer or more complicated radiographic assessments or in younger children and those with high pain levels and/or anxiety. A number of sedative agents and approaches have been described as effective for pediatric radiographic imaging. The specific approach should be determined by a number of factors including the clinical setting, patient age, provider experience, specific injury or illnesses present at the time of the procedure, and the planned imaging intervention. BIBLIOGRAPHY 1. Krauss B, Zurakowski D. Sedation patterns in pediatric and general community hospital emergency departments. Pediatr Emerg Care 1998;14:99–103. 2. Clinical policy for procedural sedation and analgesia in the emergency department. American College of Emergency Physicians. Ann Emerg Med 1998;31:663–677. 3. Practice guidelines for sedation and analgesia by non- anesthesiologists. Anesthesiology 2002;96:1004–1017. 4. American Academy of Pediatrics Committee on Drugs: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992;89:1110–1115. 5. Krauss B, Green SM. Sedation and analgesia for proce- dures in children. N Engl J Med 2000;342:938–945. 6. Green SM, Krauss B. Pulmonary aspiration risk during emergency department procedural sedation – an examina- tion of the role of fasting and sedation depth. Acad Emerg Med 2002;9:35–42. 7. Roback MG, Bajaj L, Wathen JE, Bothner J. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: Are they related? Ann Emerg Med 2004;44:454–459. 8. McQuillen KK, Steele DW. Capnography during sedation/ analgesia in the pediatric emergency department. Pediatr Emerg Care 2000;16:401–404. 9. Newman DH, Azer MM, Pitetti RD, Singh S. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedur- al sedations. Ann Emerg Med 2003;42:627–635. 10. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics 2000;105:1110–1115. 11. Mace SE, Barata IA, Cravero JP, et al. Clinical policy: Evidence-based approach to pharmacologic agents used in Pediatric Radiographic Imaging Studies 177 pediatric sedation and analgesia in the emergency depart- ment. Ann Emerg Med 2004;44:342–377. 12. Pershad J, Palmisano P, Nichols M. Chloral hydrate: The good and the bad. Pediatr Emerg Care 1999;15:432–435. 13. Moro-Sutherland DM, Algren JT, Louis PT, et al. Comparison of intravenous Midazolam with pentobarbital for sedation for head computed tomography imaging. Acad Emerg Med 2000;7:1370–1375. 14. Rothermel LK. Newer pharmacologic agents for procedural sedation of children in the emergency department – etomidate and propofol. Curr Opin Pediatr 2003;15: 200–203. 15. Ruth WJ, Burton JH, Bock AJ. Intravenous etomidate for procedural sedation in emergency department patients. Acad Emerg Med 2001;8:13–18. 16. Bassett KE, Anderson JL, Pribble CG, Guenther E. Propofol for procedural sedation in children in the emergency department. Ann Emerg Med 2003;42: 773–782. 17. Green SM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2004;44:460–471. 178 Procedural Sedation for the Emergency Patient 28 Procedural Sedation for Brief Pediatric Procedures: Foreign Body Removal, Lumbar Puncture, Bone Marrow Aspiration, Central Venous Catheter Placement Michael Ciccarelli and John H. Burton SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN/SEDATION CONSIDERATIONS SEDATION MANAGEMENT Specific Agents for Sedation/Analgesia during Brief Pediatric Procedures FOLLOW-UP/CONSULTATION CONSIDERATIONS SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM The pediatric population accounts for a large percentage of emergency department (ED) visits annually. Many of these patie nts will require brief, painful procedures either in the ED or in another setting such as the intensive care unit. These procedures also occur fre- quently in the outpatient clinic or inpatient setting for children with chronic illnesses. To affect an optimal procedural experience for these patients, a pediatric procedure unit or clinical response team of well-trained caregivers has been a recent trend. Typical procedures for these patients include lumbar puncture, bone marrow aspiration, and central venous catheter placement. These procedures, and other brief diagnostic and therapeutic procedures in this population, are similar to the adult population in the intervention and technique required. They are distinct from their adult counterparts, however, in that the pediatric patient will often require sedation and anxiolysis owing to the child’s fear, in addition to a need to create an experience that is positive and supportive instead of a recurrent, negative association with medical care. Younger patients will also often require a brief period of sedation to optimize positioning or minimize movement. It has been previously documented that there is considerable underuse of analgesia and sedation in children requiring brief, painful medical interventions. The goal of procedural sedation in this setting is to provide sedative, analgesic, and/or dissociative agents to alter recognition of pain and level of consciousness, at the same time maintaining airway reflexes in order to provide symptomatic relief of pain and anxiety. Over the last decade, there has been a relative increase in the recognition of the needs of this population and innovative approaches. These approaches include pharmacological management, caregiver training, and individualized approaches toward the needs of each child. CLINICAL ASSESSMENT The assessment of children undergoing procedural sedation and analgesia (PSA) for brief procedures is similar to the general sedation assessment. The patient assessment should include a focused history and physical examination to identify issues that may interfere with sedation or increase the risk of adverse sedation events. Discussion with the patient and family regarding risks and benefits of sedation should also be routine prior to 179 adoption of a treatment plan. Any patient whose risk of a serious adverse event outweighs the proposed benefits of sedation may be better served by delaying the procedure until a more comprehensive approach can be undertaken, such as general anesthesia in the operating suite. A focused assessment should also include any prior history of seizure, head injury, or active condition that would place the placement at risk of adverse outcome with a sedation agent that would mildly elevate intra- cranial pressure. Ketamine is an agent that has a very attractive sedation profile for many of these patients when an intramuscular or intravenous agent is consid- ered. However, ketamine is unique from other sedation agents in that it has the potential to elevate intracranial pressure, cerebral metabolism, and oxygen consump- tion. Many pediatric patients requiring brief medical procedures will have concurrent head injury or condi- tions such as seizures that should motivate a cautious consideration of the risks associated with ketamine. Similarly, the clinical assessment should include consideration of any condition that places the patient at risk of adverse outcome for a sedation agen t that may reduce central venous pressure. Many intravenous agents, such as propofol and methohexital, create the potential for significant decreases in central venous return and subsequent hypotension. Children who are considered hemodynamically unstable, or at substantial risk for hemodynamic instability, should be approached with caution when these agents are considered. PAIN/SEDATION CONSIDERATIONS Routine patient monitoring during sedation should includelevel ofconsciousness,respiratory status,vitalsigns, and oxygen saturation. The most commonly encountered adverse events during sedation in the pediatric population are respiratory depression and vomiting. Except in sce- narios that utilize very light sedation regimes, ventilation equipment, suction, and intravenous fluid resuscitation materials should be immediately available to the clinical team throughout the sedation encounter. The benefits derived from a procedural sedation approach include 1. patient experience benefits including anxiolysis, relaxation, analgesia, and amnesia; 2. improved parental satisfaction; 3. less stressful situation for medical personnel; 4. improved safety of the patient and staff when performing a medical procedure; 5. ability to satisfactorily complete the needed medical procedure. The choice of a sedative and/or analgesic approach should take into consideration all of these potential benefits within the context of the specific procedure and patient (Table 28-1). The caregiver should take into consideration an assessment of the child’sdistress prior toand anticipated during the procedure as well as the degree of pain that will be anticipated during the intervention (Figure 28-1). These considerations should direct the sedation approach, par- ticularly with regard to anemphasis on anxiolysis, sedation, and analgesia. Many nonpharmacologic approaches may suffice solely, or in part, to achieve the desired effect for the patient. These elements might include parental presence during the procedure as well a medical provider’s demeanor that is calming to the child with a reassuring, nonthreatening approach. SEDATION MANAGEMENT Multiple agents have been studied for procedural seda- tion in the pediatric population. Most studies identify- ing appropriate agents for procedural sedation in the ED and procedure-focused setting have been described in populations of pediatric patients und ergoing painful orthopedic procedures, including joint reduction and fracture reduction. Few studies have been published with a focus population of children undergoing painful procedures other than predomin antly orthopedic and laceration repair interventions. Characteristics to consider for any sedation and analgesia approach in children with brief medical pro- cedures include painless administration, a rapid onset of clinical effects, the ability to easily titrate the agent(s) to a desired level of sedation, a rapid recovery time, and limited side effects – specifically vomiting, respiratory depression, hypotension, and emergence reactions. The most commonly utilized agents in these settings are nitrous oxide, benzodiazepines (e.g., midazolam), etomidate, barbiturates (e.g., methohexital), propofol, 180 Procedural Sedation for the Emergency Patient and ketamine. Each of these agents has specific advan- tages and disadvantages that may enhance its appro- priateness for any given patient and procedure (Table 28-2). Nonpharmacologic approaches can also be useful in whole or as part of an adjunctive strategy with other agents. Additionally, anesthetic agents applied to the skin, including regional block anesthesia, should be Table 28-1. Sedation, anxiolysis, and analgesia considerations for brief painful procedures (e.g., foreign body removal, lumbar puncture, bone marrow aspiration, central venous catheter placement) in pediatric patients 1. Would the patient benefit from analgesia? Is the patient currently in pain? Will the procedure be painful? Will the patient have pain after the procedure? 2. What form of pain control is appropriate, if necessary? Nonpharmacologic, topical anesthesia, regional block anesthesia, systemic analgesia 3. Would the patient benefit from anxiolysis? 4. What form of anxiolysis is appropriate? Nonpharmacologic, oral agent (e.g., a benzodiazepine), inhaled nitrous oxide, systemic anxiolytic agent 5. Would the patient benefit from sedation? 6. What depth of sedation is appropriate? Mild, moderate, deep sedation Patient needs Depth of sedation Length of analgesia Sedation only Sedation, analgesia during procedure Sedation, analgesia during and after procedure Light Nitrous Midazolam None Moderate Midazolam Ketamine Brief Fentanyl Deep Etomidate Methohexital Propofol Ketamine Long Morphine Figure 28-1. Algorithm for approach to selected brief painful procedures in the pediatric population. Sedation for Brief Pediatric Procedures 181 [...]... Agarwal S, Mandavia DP Cardioversion of paroxysmal atrial fibrillation in the emergency department Ann Emerg Med 1999;33: 379 –3 87 ´ 8 Coll–Vincent B, Sala X, Fernandez C, et al Sedation for cardioversion in the emergency department: Analysis of effectiveness in four protocols Ann Emerg Med 2003;42 :76 7 77 2 9 Burton JH, Miner JR, Shipley ER, Strout TD, Becker C, Thode HC Propofol for emergency department... Acad Emerg Med 2001;8(1) :74 77 7 Rothermel LK Newer pharmacologic agents for procedural sedation of children in the emergency department – etomidate and propofol Curr Opin Pediatr 2003;15: 200–203 8 Havel CJ, Strait RT, Hennes H A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department Acad Emerg Med 1999;6:989–9 97 9 Bassett KE, Anderson JL, Pribble CG, Guenther... CLINICAL ASSESSMENT PAIN /SEDATION CONSIDERATIONS SEDATION MANAGEMENT FOLLOW-UP/CONSULTATION CONSIDERATIONS SUMMARY NASOGASTRIC (NG) TUBE PLACEMENT SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN /SEDATION CONSIDERATIONS PAIN /SEDATION MANAGEMENT FOLLOW-UP/CONSULTATION CONSIDERATIONS SUMMARY BIBLIOGRAPHY ABSCESS INCISION AND DEBRIDEMENT SCOPE OF THE PROBLEM Cutaneous abscesses can originate in any part of the body... orthopedic procedural sedation in a pediatric emergency department Pediatrics 2003;112:116–123 6 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 20 07; 49:454–461 7 Guenther E, Pribble C, Junkins E, Kadish H, Bassett K, Nelson D Propofol sedation by emergency physicians for... Propofol for procedural sedation in children in the emergency department Ann Emerg Med 2003;42 :77 3 78 2 10 Guenther E, Pribble CG, Junkins E, Kadish H, Bassett K, Nelson D Propofol sedation by emergency physicians for elective pediatric outpatient procedures Ann Emerg Med 2003;42 :78 3 79 1 11 Roback MG, Wathe JE, MacKenzie T, Bajaj LA randomized controlled trial of IV versus IM ketamine for sedation of pediatric... mg/kg - Always consider as deep sedation - Hypotension risk: select patients with hemodynamic/hydration stability Etomidate 0.15 mg/kg Repeat 0.1 mg/kg - Always consider as deep sedation - Consider for hemodynamic unstable patient - Myoclonus approximately 2 0-4 0% Methohexital 1 mg/kg - Always consider as deep sedation - Hypotension risk: select patients with hemodynamic/hydration stability Figure 2 9-1 ... associated with procedural sedation for any given clinical scenario, particularly in the setting of many orthopedic joint and fracture reductions PAIN /SEDATION MANAGEMENT A general approach to procedural sedation and analgesia for the patient with acute orthopedic injury requiring reduction is summarized in Figure 2 9-1 The underlying principle for the balance between sedation risk and optimization of conditions... adverse sedation events are more likely to be associated with deeper levels Procedural Sedation for the Emergency Patient of sedation, longer sedation periods, and repetitive dosing of sedative agents The selection of an agent or multiple agents for sedation and/ or analgesia during orthopedic injury reduction should vary with the anticipated complexity and urgency of the procedure (Table 2 9-1 , Figure 2 9-2 )... of IV versus IM ketamine for sedation of pediatric patients receiving emergency department pediatric procedures Ann Emerg Med 2006;48:605–612 29 Procedural Sedation for Adult and Pediatric Orthopedic Fracture and Joint Reduction James Miner and John H Burton SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN /SEDATION MANAGEMENT PAIN /SEDATION CONSIDERATIONS FOLLOW UP/CONSULTATION SUMMARY BIBLIOGRAPHY SCOPE... Procedural sedation of critically ill patients in the emergency department Acad Emerg Med 2005;12:124–128 30 Procedural Sedation for Electrical Cardioversion Christopher J Freeman SCOPE OF THE PROBLEM CLINICAL ASSESSMENT PAIN CONSIDERATIONS PAIN MANAGEMENT FOLLOW-UP CONSIDERATIONS SUMMARY BIBLIOGRAPHY SCOPE OF THE PROBLEM The first use of electricity in resuscitation was described in 177 4 by the Royal . (Table 2 7- 2 ). PAIN /SEDATION MANAGEMENT There are a variety of agents available and suitable for procedural sedation for pediatric imaging studies Table 2 7- 1 . Factors to consider for procedural sedation. procedural sedation and analgesia in the emergency department. American College of Emergency Physicians. Ann Emerg Med 1998;31:663– 677 . 3. Practice guidelines for sedation and analgesia by non- anesthesiologists Imaging Studies 177 pediatric sedation and analgesia in the emergency depart- ment. Ann Emerg Med 2004;44:342– 377 . 12. Pershad J, Palmisano P, Nichols M. Chloral hydrate: The good and the bad. Pediatr