the 3 p's of control
TRANSCRIPT
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Pediatric Pediatric Analgesia and Analgesia and Sedation for Sedation for
Painful Painful ProceduresProcedures
Lou E. Romig MD, FAAP, FACEPMiami Children’s Hospital Emergency Medicine
www.jumpstarttriage.com
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A.K.A…A.K.A…
In the ED, Sedation &Analgesia beats the
heck out of S&M!
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Hypersonic screams!
Punctured
eardrums! Hysterical parents!
This kind of S&M…
Kicks and
bites in the …!
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Why talk about Why talk about these things at these things at
an EMS an EMS conference?conference?
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Sedation & Analgesia and EMSSedation & Analgesia and EMS
We’re all on the same team.
Knowing what may happen in the ED can help in patient and family management.
Relieving pain should be considered an EMS task.
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Sedation & Analgesia and EMSSedation & Analgesia and EMS
Some of the drugs used for S&A are also used in the field.
Many EMS providers also work in an Emergency Department or Outpatient care setting.
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If this were your child…?If this were your child…?
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Objectives:Objectives:
1) State the differences between sedation, anesthesia, and analgesia.
2) Discuss the physiological and psychological effects of pain and anxiety in children.
3) Name 2 sedatives, 2 analgesics and 1 anesthetic commonly used for pediatric outpatient procedures.
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Objectives:Objectives:
1) List the most commonly used routes to deliver sedation and analgesia for children, as well as examples of medications used by each route.
2) Review the potential complications of conscious sedation and parenteral analgesia in children and recommended monitoring procedures.
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SedationSedation
A medically induced state of depressed level of consciousness
Used to facilitate the smooth and uninterrupted performance of a procedure
Used to reduce patient anxiety and improve cooperation
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SedationSedation
Usually done at level of conscious sedation
Protective airway reflexes are preserved
Maintains own airway
Appropriate response to verbal command or stimulation
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SedationSedation
Rarely done at level of deep sedation
Protective airway reflexes may be compromised
May require assistance maintaining airway
No purposeful response to verbal command or painful stimulus
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Sedation is a balancing actSedation is a balancing act
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Uses for SedationUses for Sedation
Diagnostic studies
CT/MRI
Lumbar puncture
Joint tap
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Uses for SedationUses for Sedation
Therapeutic interventions
Wound management
Fracture/dislocation reduction and immobilization
Incision and drainage
Dental procedures
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AnesthesiaAnesthesia
General:Medically induced state of unconsciousness accompanied by amnesia and analgesia
Local/regional:Procedure resulting in the blocking of pain sensation by direct action upon the sensory nerves
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Indications for Anesthesia:Indications for Anesthesia:
Inability to provide adequate analgesia due to intensity or nature of pain during procedure
May be used in conjunction with sedation and/or analgesia
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Indications for AnesthesiaIndications for Anesthesia
Local and regional anesthetic blocks are commonly used for wound care, orthopedic, and dental procedures.
Local or regional blocks are occasionally used for longer duration outpatient pain management.
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AnalgesiaAnalgesia
Medical treatment forthe relief or prevention of pain.
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AnalgesiaAnalgesia
Indication:
PAIN
Contraindications:
Inability to tolerate analgesic agents
Procedure requires that patient be able to indicate when he/she feels pain
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Note that youth is Note that youth is not a not a
contraindication contraindication for pain for pain
management!management!
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Why treat pain Why treat pain and anxiety inand anxiety in
children?children?
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Psychological EffectsPsychological Effects
Pain and anxiety can be traumatic psychological experiences.
Fear of and lack of trust for medical personnel and other caregivers
Fear, anxiety and guilt among family members
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Physiological EffectsPhysiological Effects
Release of catecholamines
Elevated heart rate
Elevated blood pressure
Elevated respiratory rate
Increased oxygen demand
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Physiological EffectsPhysiological Effects
Vagal stimulationFainting
Low heart rate
Low blood pressure
Breath holding
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Pain and anxietyPain and anxiety
Healthy children can tolerate the physiologic effects well.
Frail children may not tolerate the altered physiology well but are also at higher risk of complications, more from sedation than from analgesia.
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The body remembers…
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Grunau R. Early pain in preterm infants. A model of long-term effects.Grunau R. Early pain in preterm infants. A model of long-term effects.Clin Perinatol. 2002 Sep;29(3):373-94, vii-viii.Clin Perinatol. 2002 Sep;29(3):373-94, vii-viii.
“In vulnerable prematurely born infants, repeated and prolonged pain exposure may affect the subsequent
development of pain systems, as well as potentially contribute to alterations
in long-term development and behavior.”
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Sedation
Anesthesia
Analgesia
?
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Choosing an InterventionChoosing an Intervention
Is the patient already in pain?
Analgesia
Will the procedure cause pain?
Analgesia
Anesthesia
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Choosing an InterventionChoosing an Intervention
Is the patient anxious or likely to be anxious during the procedure (even with pain management)?
Patient movement
Need for cooperation
Physiologic effects of anxiety may interfere with procedure
Psychological trauma
Behavioral interventionSedation
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Anesthesia
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Indications for use:Indications for use:
Inability to provide adequate analgesia due to intensity or nature of pain during procedure
May be used in conjunction with sedation and/or analgesia
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““Caine” anestheticsCaine” anesthetics
Lidocaine most commonly used
Applied locally by injection at the injured area
Applied by injection at nerve sites to block pain in regions
Applied intravenously to provide anesthesia in an area of intentionally restricted circulation
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““Caine” anestheticsCaine” anesthetics
Duration of anesthesia depends upon agent used
Lidocaine works for 30-60 minutes
Must ask about potential allergies to all anesthetic agents incorporating the “caine” suffix
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““Caine” anestheticsCaine” anesthetics
Toxicity:
Dizziness, drowsiness
Agitation, confusion, hearing loss
Seizures, coma
Bradycardia, hypotension
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Sedation
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Indications for sedationIndications for sedation
Need to facilitate cooperation
Need for a complicated or extended procedure
Desire for amnesia
Relief of muscle spasm
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SedativesSedatives
Chloral hydrate
Oral or rectal administration
30-45 minutes before onset of action
Long period of sedation, length variable
Not suited for emergency outpatient ortho procedures
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SedativesSedatives
Demerol, Phenergan, Thorazine (DPT)
No longer in common use
Intramuscular administration
Long time to offset
Phenergan and thorazine can cause extrapyramidal reactions
Demerol can cause nausea, vomiting
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SedativesSedatives
Benzodiazepines
Diazepam, midazolam most commonly used
PO, PR, IM, IV, nasal (midazolam)
Time to effect depends on route of administration
Diazepam works well for muscle spasms
Midazolam has excellent amnestic effects
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SedativesSedatives
Ketamine
Most effective when used IV
May induce post-emergence agitation
Often used in combination with benzodiazepines
Rapid onset, variable offset
Excellent sedation, amnesia and analgesia
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SedativesSedatives
Barbiturates
Nembutal most commonly used
PO, PR, IV
Onset of action dependent upon route of administration (several minutes to up to an hour)
Depressive effects potentiated by concomitant use of benzodiazepines
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ComplicationsComplications
Sedatives do NOT necessarily provide analgesia
Vomiting, aspiration
Respiratory depression
Circulatory depression
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PrecautionsPrecautions
Assess risks due to acute or chronic illnesses
Assess NPO status
Assess ability to manage a compromised airway
Provide constant physiologic monitoring
Perform only in a setting where immediate advanced life support interventions are available
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Analgesics
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In general, pain is under-treated in
children.
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Indications for AnalgesiaIndications for Analgesia
PAIN at any age!
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Don’t Forget!Don’t Forget!
Proper immobilization, positioning and
application of ice can be very effective in treating and even preventing pain.
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AnalgesicsAnalgesics
Non-narcotic
Acetaminophen PO, PR
Ibuprofen PO
Ketoralac PO, IM, IV
No difference demonstrated in effectiveness between ibuprofen and ketoralac
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AnalgesicsAnalgesics
Narcotics
Morphine IM, IV
Demerol IM, IV
Fentanyl IV, PO
Codeine and analogs PO
Morphine and demerol may cause nausea, vomiting, and histamine release
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AnalgesicsAnalgesics
Nitrous oxide
Rapid onset and offset of analgesia
Requires special equipment for administration
Requires cooperative patient
Does not work well for reduction of acute, sharp pain such as that of fracture reduction
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Complications of AnalgesiaComplications of Analgesia
Respiratory depression with parenteral administration
Sedation
Nausea, vomiting
Constipation (codeine)
Unintentional overdose
Addiction is not a consideration
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RisksRisks BenefitsBenefits
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Risks To PatientRisks To Patient
Potential complications due to medications used
Potential psychological and physiological complications due to pain and anxiety
Potential for sub optimal outcome of procedure due to poor patient cooperation
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Risks to Medical CaregiversRisks to Medical Caregivers
Responsibility for assessing and managing all potential complications
Alienation of child and family against medical caregivers
Professional satisfaction
Personal impact
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Benefits to PatientsBenefits to Patients
Reduction or elimination of pain and anxiety
Maintaining trust and confidence in medical caregivers
Helping family caregivers to better deal with the child’s trauma
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Benefits to Medical CaregiversBenefits to Medical Caregivers
Improved interactions with children and their families
Better professional performance
Greater personal satisfaction and gratification
Less fear of treating children
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Take Home LessonsTake Home Lessons
There is no excuse for giving inadequate analgesia to children.
Sedation may be indicated for the benefit of the child, the family, and the caregivers but must be done with careful consideration of the risks.
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The End.The End.Thank You!Thank You!