1
Procedural Sedation and Analgesia in the Emergency Department
Itai Shavit, MD
Unfortunately, this is usually not what we see in the ED …
Pain and suffering go together
Acute Pediatric Pain
Children may experience severe painChildren may experience severe pain
What if this was your child ?What if this was your child ?
Do we really need to treat Do we really need to treat Pediatric pain in the ED?Pediatric pain in the ED?
(Ethics?)(Ethics?)
There is no ethical justification to withhold analgesia when a child is clearly
in pain
““Children are not just the people of Children are not just the people of tomorrow, they are people today” tomorrow, they are people today”
(Janusch Korchak)(Janusch Korchak)
מינהל רפואהמינהל רפואה
מדינת ישראל - משרד הבריאות החטיבה לענייני
בריאות
הנדון: סדציה בילדים על ידי רופא שאינו מרדים
על כל מטפל חלה החובה למזער את הכאב והפגיעה בילדים ...""....בכל האמצעים העומדים לרשותו
2003במאי 13
Pain is an EmergencyPain is an Emergency
Relieving pain & anxiety
are an ED task!!
(today’s standard of care)
We have all experienced pain …We have all experienced pain …
PAIN ASSESSMENTPAIN ASSESSMENT
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
Anxiety decreases pain threshold (Fear makes every pain greater)
Types of pain:Types of pain:
Pain on presentation -Due to injury -Due to illness
Procedure-related pain (the pain we create)
Fractures, Burns, Amputations
Due to injuryDue to injury
Pain on presentationPain on presentation
Due to illnessDue to illness
Peritonitis, Sickle cell crisis, Otitis Media, Migraine
Severe pain Severe pain Severe pain
Severe pain Severe pain
Severe pain should be treated Severe pain should be treated ASAPASAP
The pain we create!The pain we create!
Fracture reduction, Lacerations repair,
Urine Cathetherization , Spinal tap,
Arthrocentesis, IVs
Procedure-related painProcedure-related pain
Procedure-related pain may be sometimes painful
but it is always stressful
Children younger than 8 years are not able to understand that short term pain may have long term benefit
“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”.
Procedural Sedation and Analgesia Procedural Sedation and Analgesia (PSA) (PSA)
American College of Emergency Physicians, 1998American College of Emergency Physicians, 1998
(מ.ס.קורס סדציהר, 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
(מ.ס.קורס סדציהר, תל השומר)
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!)
Practicing Sedation and Analgesia in Practicing Sedation and Analgesia in the ER …the ER …
Non pharmacological sedation Non pharmacological sedation Parental distraction techniques
Quite environment, toys, books, music
““Hei Doc, tell me what’s going on….”Hei Doc, tell me what’s going on….”“….don’t take my mom away”“….don’t take my mom away”
PSA - MedicationsPSA - Medications
Opioids Non-opioid Benzodiazepins Barbiturates Etomidate
Propofol
Nitrous Oxide
Ketamine
Analgesic agents Sedative/HypnoticsDissociative
agentInhalational
agent
Fentanyl
Morphine
Midazolam
Meperidine?
Methohexital
Topical Analgesia
OxycodeTramadol (Atypical opioid)
Ibuprofen
Nurofen Advil
Emla, AmetopGel, LET, TAC
Morphine
Morphine
Continuum depth of SedationContinuum depth of Sedation
Level of consciousness
Deep
sedation
General
Anesthesia
Minimal sedation (anxiolysis)
Moderate (conscious) sedation
Protective
Reflexes
Present Present Present/
potential loss
Total
loss
Probable
loss
Awake
Midazolam (P.O./I.N. 0.3 mg/kg)
Midazolam (P.O./I.N. 0.5 mg/kg)
Nitrous oxide
Chloral hydrate
(Triclonam)
Ketamine
Fentanyl
Propofol
Combinations
OR only/
Anesthesiologist
Non pharmacologic
Normal response to verbal stimulation
Purposeful response to verbal or tactile stimulation
Purposeful response following repeated or painful stimulation
Unarousable even with painful stimulation
THNX