Transcript The 3 P`s of Control - JumpSTART Pediatric MCI Triage Tool

Pediatric
Analgesia and
Sedation for
Painful
Procedures
Lou E. Romig MD, FAAP, FACEP
Miami Children’s Hospital Emergency Medicine
www.jumpstarttriage.com
A.K.A…
In the ED,
S &A
beats the
heck out of
S&M!
edation
nalgesia
This kind of S&M…
Hypersonic
screams!
Why talk about
these things at
an EMS
conference?
Sedation & 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.
Sedation & 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.
If this were your child…?
Objectives:
1)
2)
3)
State the differences between sedation,
anesthesia, and analgesia.
Discuss the physiological and
psychological effects of pain and anxiety
in children.
Name 2 sedatives, 2 analgesics and 1
anesthetic commonly used for pediatric
outpatient procedures.
Objectives:
4)
List the most commonly used routes
to deliver sedation and analgesia for
children, as well as examples of
medications used by each route.
5)
Review the potential complications
of conscious sedation and parenteral
analgesia in children and
recommended monitoring
procedures.
Sedation
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
Sedation
Usually done at level of conscious
sedation
Protective airway reflexes are
preserved
Maintains own airway
Appropriate response to verbal
command or stimulation
Sedation
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
Sedation is a balancing act
Uses for Sedation
Diagnostic studies
CT/MRI
Lumbar puncture
Joint tap
Uses for Sedation
Therapeutic interventions
Wound management
Fracture/dislocation reduction
and immobilization
Incision and drainage
Dental procedures
Anesthesia
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
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
Indications 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.
Analgesia
Medical treatment for
the relief or prevention of pain.
Analgesia
Indication:
PAIN
Contraindications:
Inability to tolerate analgesic
agents
Procedure requires that patient
be able to indicate when he/she
feels pain
Note that youth is
not a
contraindication
for pain
management!
Why treat pain
and anxiety in
children?
Psychological 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
Physiological Effects
Release of catecholamines
Elevated heart rate
Elevated blood pressure
Elevated respiratory rate
Increased oxygen demand
Physiological Effects
Vagal stimulation
Fainting
Low heart rate
Low blood pressure
Breath holding
Pain 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.
The body remembers…
“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.”
Grunau R. Early pain in preterm infants. A model of long-term effects.
Clin Perinatol. 2002 Sep;29(3):373-94, vii-viii.
?
Choosing an Intervention
Is the patient already in pain?
Analgesia
Will the procedure cause pain?
Analgesia
Anesthesia
Choosing 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 intervention
Sedation
Anesthesia
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
“Caine” 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
“Caine” 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
“Caine” anesthetics
Toxicity:
Dizziness, drowsiness
Agitation, confusion, hearing
loss
Seizures, coma
Bradycardia, hypotension
Sedation
Indications for sedation
Need to facilitate cooperation
Need for a complicated or
extended procedure
Desire for amnesia
Relief of muscle spasm
Sedatives
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
Sedatives
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
Sedatives
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
Sedatives
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
Sedatives
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
Complications
Sedatives do NOT necessarily
provide analgesia
Vomiting, aspiration
Respiratory depression
Circulatory depression
Precautions
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
Analgesics
In general, pain is
under-treated in
children.
Indications for Analgesia
PAIN at any age!
Don’t Forget!
Proper
immobilization,
positioning and
application of ice can
be very effective in
treating and even
preventing pain.
Analgesics
Non-narcotic
Acetaminophen PO, PR
Ibuprofen PO
Ketoralac PO, IM, IV
No difference demonstrated in
effectiveness between ibuprofen and
ketoralac
Analgesics
Narcotics
Morphine IM, IV
Demerol IM, IV
Fentanyl IV, PO
Codeine and analogs PO
Morphine and demerol may cause
nausea, vomiting, and histamine
release
Analgesics
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
Complications of Analgesia
Respiratory depression with parenteral
administration
Sedation
Nausea, vomiting
Constipation (codeine)
Unintentional overdose
Addiction is not a consideration
Risks
Benefits
Risks 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
Risks to Medical Caregivers
Responsibility for assessing and
managing all potential complications
Alienation of child and family
against medical caregivers
Professional satisfaction
Personal impact
Benefits 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
Benefits to Medical Caregivers
Improved interactions with children
and their families
Better professional performance
Greater personal satisfaction and
gratification
Less fear of treating children
Take 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.
The End.
Thank You!