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

ELA-max: A New Topical Lidocaine Formulation

OBJECTIVE

To evaluate the role of a new formulation of lidocaine (ELA-max) in local anesthesia in children and compare it with the eutectic mixture of local anesthetics (EMLA).

DATA SOURCES

Relevant literature was identified by a MEDLINE search (1966—November 2003) using the search terms ELA-max and EMLA. Bibliographies of selected articles were also examined to include all relevant investigations. The product manufacturer was contacted for inclusion of the most recent data available.

DATA SYNTHESIS

Topical anesthesia in children is clinically challenging. ELA-max has been shown to be as effective as EMLA for venipuncture in children, but with faster onset. Adverse effects, such as transient blanching with redness and erythema, have been reported.

CONCLUSIONS

Further investigation is needed to determine the effectiveness of ELA-max on other painful procedures in children, as well as its safety.

Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study

INTRODUCTION

Provision of rapid, painless and effective analgesia to children remains problematic in the prehospital and emergency setting. Intranasal fentanyl has the potential to eliminate many of the problems of narcotic administration in children. The aim of this study, conducted in a tertiary paediatric emergency department was to evaluate the safety and efficacy of intranasal fentanyl in children.

METHODS

Children in acute pain aged between three and 12 years inclusive were enrolled on presentation to the emergency department. Routine observations and pain scoring by the child and caregiver was undertaken prior to the child receiving fentanyl (20 micrograms for 3-7 year olds and 40 micrograms for 8-12 year olds) and at intervals of 5 min for 30 min Additional fentanyl at the dose of 20 micrograms was given 5 minutely as required. Caregivers and older children used a visual analogue scale (VAS) and the younger children used the Wong-Baker faces scale (WBS).

RESULTS

Forty five children were enrolled with a mean age of 8.0 years. The median dose of fentanyl administered was 1.5 micrograms/kg. Mean pain score in 32 children using the VAS was 62.3 mm (95% confidence interval 53.2-69.4 mm) at presentation and reduced at 10 min to 44.6 mm (95% confidence interval 36.2-53.1 mm). In 16 children using WBS the initial mean reading was 4.0 (95% confidence interval 3.3-4.7) and reduced to 2.2 (95% confidence interval 1.3-3.1) at 10 min. Caregiver pain scores showed a mean preintervention pain score of 64.9 mm (95% confidence interval 57.7-72.2 mm) with a significant reduction at 10 min to 41.7 mm (95% confidence interval 34.7-48.6 mm). There was no significant alteration in pulse rate, respiratory rate, and blood pressure or oxygen saturations. There were no negative side-effects.

CONCLUSIONS

Early and significant reduction in pain (compared to baseline assessments) was achieved in children using intranasal fentanyl by 10 min and sustained throughout the 30 min of observations. This raises the possibility of using intranasal fentanyl in children in the prehospital setting as well as a role for this form of analgesia as triage nurse-initiated administration in the emergency department.

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.

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.