Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children

Orthopedic fractures and joint dislocations are among the most painful pediatric emergencies. Safe and effective management of fracture-related pain and anxiety in the emergency department reduces patient distress during initial evaluation and often allows definitive management of the fracture. No consensus exists on which pharmacologic regimens for procedural sedation/analgesia are safest and most effective. For some children, control of fracture pain is the primary goal, whereas for others, relief from anxiety is an additionally important objective. Furthermore, strategies for the management of fracture pain may vary by fracture location and patient characteristics; thus, no single regimen is likely to provide the best means of analgesia and anxiolysis for all patients. Effective analgesia can be provided by local or regional anesthesia, such as hematoma, Bier, or nerve blocks. Alternatively, induction of deep sedation with analgesic agents such as ketamine or fentanyl, often combined with sedative-anxiolytic agents such as midazolam, may be used to manage distress associated with fracture reduction. A combination of local anesthesia with moderate sedation, for example nitrous oxide, is another attractive option.

Sedation for peritonsillar abscess drainage in the pediatric emergency department

OBJECTIVE

To evaluate the use of intravenous (IV) sedation in children during peritonsillar abscess (PTA) incision and drainage in the emergency department (ED).

DESIGN

Retrospective review of medical records of children with a diagnosis of PTA.

SETTING

The ED of a large, urban, academic children's hospital.

PATIENTS

Consecutive patients 18 years or younger presenting from April 1995 to November 1998.

METHODS

Information was retrieved from a time-based sedation record that included age, sex, ASA classification, time since last liquid or solid, agent and dose, level of sedation (A=alert, V=response to voice, P=purposeful response to pain, U=unresponsive), vital signs, complications, recovery time, and disposition.

RESULTS

Forty-two patients had incision and drainage performed with IV sedation in the ED. Mean age was 11.3 +/- 4.3 years (range 4-18 years); 57% were African-American, and 64% were female. Agents used included ketamine plus midazolam (K/M) (n = 36, 86%), morphine plus midazolam (n = 3, 7%), meperidine plus midazolam (n = 2, 5%), and nitrous oxide plus midazolam (n = 1, 2%). No cardiorespiratory complications, including laryngospasm, occurred. Vomiting occurred in 1 patient who received meperidine and midazolam. The deepest level of sedation reached included: 12% A, 64% V, and 24% P. No patient who had an abscess drained in the ED with IV sedation was admitted, and mean recovery time was 81.0 +/- 30.1 minutes.

CONCLUSIONS

IV sedation in children for incision and drainage of PTA by skilled personnel in the ED may eliminate the need for admission and surgical drainage in the operating room. K/M was used most frequently, without adverse effect, and all patients were discharged from the ED. Because K/M may result in deep sedation, appropriate personnel and equipment must be present.

Maintenance of column performance at scale

Pack-in-place column packing methods were developed for Q Sepharose Big Beads at 40 cm I.D. and scaled up to 200 cm I.D. in Chromaflow columns. The efficiency and asymmetry of the packed bed were evaluated as a function of test velocity and sample volume. The performance of the packed beds at both scales approached the theoretical limits of column performance (Hred =2 and Af=1) expected in small analytical columns. The packing strategy was effective for scale up and the stability of the packed beds, the effectiveness of the column design with respect to the mobile phase distribution system and the stability of the media to the pack-in-place technology, are presented.

Pharmacological management of pain and anxiety during emergency procedures in children

Painful procedures are frequently required during treatment of children in the emergency department and are very stressful for the children, their parents and healthcare providers. Pharmacological methods to safely provide almost painless local anaesthesia, analgesia and anxiolysis have been increasingly studied in children. With knowledge of these methods, and patience, the emergency care provider can greatly reduce the distress often associated with emergency care of children. Topical local anaesthetics such as LET [lidocaine (lignocaine), epinephrine (adrenaline), tetracaine] or buffered lidocaine injected through the wound with fine needles can almost painlessly anaesthetise lacerations for suturing. Topical creams such as lidocaine/ prilocaine (EMLA) or tetracaine, iontophoresed lidocaine, or buffered lidocaine subcutaneously injected with fine needles can make intravenous catheter placement virtually 'painless'. When anxiety is significant, and mild to moderate analgesia/ anxiolysis/amnesia is needed, nitrous oxide can be administered if the proper delivery devices are available. Alternatively, when intensely painful fracture reduction, burn debridement, or abscess drainage is necessary, well tolerated and effective deep sedation can be achieved with careful use of midazolam and either ketamine or fentanyl.

A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair

STUDY OBJECTIVE

To compare the efficacy and complication profile of oral midazolam therapy and continuous-flow 50% nitrous oxide in alleviating anxiety during laceration repair in children 2 to 6 years old.

METHODS

We conducted a prospective, randomized clinical trial using 4 study groups who required laceration repair: (1) children who received standard care alone, which included comforting and topical anesthesia augmented with injected lidocaine if needed; (2) children who received standard care and oral midazolam; (3) children who received standard care and nitrous oxide; and (4) children who received standard care, oral midazolam, and nitrous oxide. Videotapes were blindly scored using the Observational Scale of Behavioral Distress-Revised (OSBD-R) to assess distress during baseline, wound cleaning, lidocaine injecting, suturing, and recovery. Adverse effects were noted during suturing and by parent questionnaires completed 24 hours after suturing and at suture removal. OSBD-R data were analyzed using repeated-measures analysis of variance. Adverse effect data were analyzed using categorical models.

RESULTS

Two hundred four subjects were enrolled (midazolam plus nitrous oxide 52, midazolam 51, nitrous oxide 51, standard care 50; mean patient age was 4.1 years; 66% were boys). Mean OSBD-R scores were lower for groups that received nitrous oxide during wound cleaning by 2.2 points (95% confidence interval [CI] 1.1 to 3.2), lidocaine injecting by 2.5 points (95% CI 1.4 to 3.5), and suturing by 2.9 (95% CI 1.8 to 3.9). Adverse effects occurred more frequently, and recovery times were longer for groups that received midazolam.

CONCLUSION

For facial suturing in 2- to 6-year-old children, regimens including continuous-flow nitrous oxide were more effective in reducing distress, and had fewer adverse effects and shorter recovery times than midazolam.

The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department

Painful and frightening injuries and illnesses are frequent reasons for children to seek care in an emergency department. Painful therapeutic procedures are often a necessary part of emergency care and are very distressful for the children, their parents, and healthcare providers. Inadequately relieved pain and distress have acute and long-term consequences, yet methods for pain and anxiety reduction during frightening minor and major procedures are often not used because of lack of detailed knowledge of techniques and fear of adverse effects. This article reviews psychologic and pharmacologic means of safe and effective reduction of anxiety and pain during emergency department procedures.

Continuous-flow delivery of nitrous oxide and oxygen: a safe and cost-effective technique for inhalation analgesia and sedation of pediatric patients

Nitrous oxide (N2O) safely and rapidly alleviates the pain and distress of minor procedures in the emergency department (ED). We have found self-administration in children does not consistently achieve acceptable analgesia and sedation. The equipment generally available for ED use is designed for adults and delivers 50% N2O through a demand valve that requires an inspiratory effort of -3 to -5 cm of water to activate gas flow. This is difficult for young children who are crying, have more shallow respirations than adults, or cannot follow instructions. In collaboration with the Departments of Anesthesiology, Dentistry, and Respiratory Therapy, we constructed a continuous-flow system for delivering N2O and oxygen (O2). The following is a description of the components, assembly, and use of a continuous-flow machine that safely and inexpensively delivers N2O and O2 to children.

Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies

OBJECTIVE

Emergency management of pediatric fractures and dislocations requires effective analgesia, yet children's pain is often undertreated. We compared the safety and efficacy of fentanyl- versus ketamine- based protocols.

METHODOLOGY

Patients 5 to 15 years of age needing emergency fracture or joint reduction (FR) were randomized to receive intravenous midazolam plus either fentanyl (F/M) or ketamine (K/M). Measures of efficacy were observational distress scores and self- and parental-report. Measures of safety were frequency of abnormalities in and need for support of cardiopulmonary function and other adverse effects.

RESULTS

During FR, K/M subjects (n = 130) had lower distress scores and parental ratings of pain and anxiety than did F/M subjects (n = 130). Although both regimens equally facilitated reductions, deep sedation, and procedural amnesia, orthopedists favored K/M. Recovery was 14 minutes longer for K/M. Fewer K/M subjects had hypoxia (6% vs 25%), needed breathing cues (1% vs 12%), or required oxygen (10% vs 20%) than did F/M subjects. Two K/M subjects required assisted ventilation briefly. More K/M subjects vomited. Adverse emergence reactions were rare but equivalent between regimens.

CONCLUSIONS

During emergency pediatric orthopedic procedures, K/M is more effective than F/M for pain and anxiety relief. Respiratory complications occurred less frequently with K/M, but respiratory support may be needed with either regimen. Both regimens facilitate reduction, produce amnesia, and rarely cause emergence delirium. Vomiting is more frequent and recovery more prolonged with K/M.