1. Procedural Sedation and Analgesia in the Emergency Department
Slide 1: Pediatric Advanced Life Support Science Update
Note to instructors: These notes provide background information for the instructor. The information is not designed to be read to the participants.
The instructor should select the slides to be used according to the participants’ interests and expertise. Generally a maximum of 30 to 45 slides should be used. Using the Slide Sorter View, the instructor should move any slides that won’t be used to the end of the presentation. Eight optional slides are provided at the end of this series. In general, if you add an optional slide into the set you should try to remove a slide to avoid making the lecture too long.
Itai Shavit, MD 1

2. Unfortunately, this is usually not what we see in the ED …

3. Pain and suffering go together

4. Acute Pediatric Pain

5. Children may experience severe pain
What if this was your child ?

6. Do we really need to treat Pediatric pain in the ED? (Ethics?)
There is no ethical justification to withhold analgesia when a child is clearly in pain

7. “Children are not just the people of tomorrow, they are people today”
(Janusch Korchak)

8. מינהל רפואה מדינת ישראל - משרד הבריאות החטיבה לענייני בריאות
13 במאי 2003
מינהל רפואה
הנדון: סדציה בילדים על ידי רופא שאינו מרדים
"... על כל מטפל חלה החובה למזער את הכאב והפגיעה בילדים בכל האמצעים העומדים לרשותו...."

9. Relieving pain & anxiety (today’s standard of care)
Pain is an Emergency
Relieving pain & anxiety
are an ED task!!
(today’s standard of care)

10. We have all experienced pain …
PAIN ASSESSMENT
We have all experienced pain …

11. Inability to verbalize pain appropriately under 2 years of age
Inability to verbalize pain appropriately under 2 years of age. At age 3-7 most children are competent to provide accurate information (using assessment tools)
Behavioral pain measures are more useful than physiological parameters. Physiologic parameters are unreliable

12. Anxiety decreases pain threshold
(Fear makes every pain greater)

13. Types of pain: Procedure-related pain (the pain we create)
Pain on presentation Due to injury Due to illness
Procedure-related pain (the pain we create)

14. Fractures, Burns, Amputations
Pain on presentation
Due to injury
Severe pain
Severe pain
Severe pain
Fractures, Burns, Amputations
Due to illness
Severe pain
Severe pain
Peritonitis, Sickle cell crisis, Otitis Media, Migraine

15. Severe pain should be treated ASAP

16. Morphine?
Studies document fever fear and misinformation among the lay public and medical professionals from the US, Great Britain, Saudi Arabia, Israel, the Netherlands. Personal experience with Kosovars and local clinics

17. Fracture reduction, Lacerations repair,
Procedure-related pain
The pain we create!
Fracture reduction, Lacerations repair,
Urine Cathetherization , Spinal tap,
Arthrocentesis, IVs

18. Procedure-related pain may be
sometimes painful
but
it is always stressful

19. Children younger than 8 years are not able to understand that short term pain may have long term benefit

20. Procedural Sedation and Analgesia (PSA)
קורס סדציה (מ.ס.ר, תל השומר)
Procedural Sedation and Analgesia (PSA)
American College of Emergency Physicians, 1998
“A Technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia is intended to result in a depressed level of consciousness but one that allows the patient to maintain airway control independently and continuously. Specifically, the drugs, doses, and techniques used are not likely to produce a loss of protective airway reflexes”.

21. Safe environment resuscitation space, resuscitation equipment
קורס סדציה (מ.ס.ר, תל השומר)
Safe environment resuscitation space, resuscitation equipment
Trained Personnel PALS & Pediatric sedation course trained, at least 2 personnel - one is responsible for sedation only
Documented & accepted hospital protocol Recording
Informed consent

22. Sedation – reduces the state of awareness
Analgesia – reduces or eliminates the perception of pain
Amnesia – Inability to remember an event or experience (babies do remember the painful experience!)

23. Practicing Sedation and Analgesia in the ER …

24. Non pharmacological sedation
Parental distraction techniques
Quite environment, toys, books, music
“Hei Doc, tell me what’s going on….” “….don’t take my mom away”

25. Tramadol (Atypical opioid)
PSA - Medications
Dissociative agent
Inhalational agent
Analgesic agents
Sedative/Hypnotics
Etomidate
Propofol
Opioids
Benzodiazepins
Barbiturates
Ketamine
Nitrous Oxide
Non-opioid
Fentanyl
Ibuprofen
Midazolam
Methohexital
Morphine
Nurofen Advil
Morphine
Oxycode
Tramadol (Atypical opioid)
Topical Analgesia
Morphine
Meperidine?
Emla, AmetopGel, LET, TAC

26. Chloral hydrate (Triclonam)
Continuum depth of Sedation
Purposeful response following repeated or painful stimulation
Unarousable even with painful stimulation
Purposeful response to verbal or tactile stimulation
Normal response to verbal stimulation
Deep
sedation
General
Anesthesia
Level of consciousness
Awake
Minimal sedation (anxiolysis)
Moderate (conscious) sedation
Protective
Reflexes
Present
Present
Present/
potential loss
Probable
loss
Total
loss
Non pharmacologic
Midazolam (P.O./I.N. 0.5 mg/kg)
Ketamine
Fentanyl
Propofol
Combinations
OR only/
Anesthesiologist
Midazolam (P.O./I.N. 0.3 mg/kg)
Nitrous oxide
Chloral hydrate (Triclonam)

27. THNX