paedriatic studies

8/13/2019 paedriatic studies

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Analgesia and Sedation in the

Emergency Department

Dr Ffion Davies

Consultant in EmergencyMedicine


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Acute Pain


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Acute Pain

Very little high quality research exists on pain

assessment tools and treatment of pain / sedation in

Emergency Departments

However pain is the main reason for attending the ED

(eg. injuries, otitis media, abdominal pain)


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Its not just the pain of the condition..

Situation drama

Parents upset

Fear of the injury itself

Foreign environment

Fear of unknown what will happen to me?

Procedures / Rx may be painful


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Dont forget the simple things

Non-pharmacological

therapy -

Splints clingfilm for burns etc


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We need to use an appropriate pain

assessment tool

This is the childs first time of using therefore

has to be easyHas to be rough and ready due to timeconstraints & distractions


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UK guideline and pain tools for ED use

College of Emergency Medicine

Pain in children guideline July 2013www.collemergencymed.ac.uk

Alder Hey Pain Tool (validated)http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&

pubmedid=15210492
http://www.collemergencymed.ac.uk/http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15210492http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15210492http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15210492http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15210492http://www.collemergencymed.ac.uk/


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l i h f f i i hild i &


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Assess pain severityUse splints / slings / dressings etc

Consider other causes of distress*

For procedures consider regionalblocks and conscious sedation

MILD PAIN

Oral/rectal paracetamol

20 mg/kg loading dose,then 15 mg/kg4-6 hourlyand / or

Oral ibuprofen 10mg/kg 6-8 hourly

MODERATE PAINAs for mild pain

plus

oral/rectal diclofenac 1mg/kg 8 hourly (unlessalready had ibuprofen)

and / or

Oral codeine phosphate1 mg/kg 4-6 hourly if

over 12 years old

SEVERE PAINConsider Entonox as holding

measurethen

Intranasal diamorphine 0.1 mls(see table)

followed by / orIV morphine 0.1-0.2 mg/kgbacked up by oral analgesics

BAEM Algorithm for treatment of acute pain in children in A&E


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Parenteral analgesia

Inhaled, 1-2 doses (intranasal diamorphine / fentanyl

or methoxyflurane)

Inhaled, continuous (N2O)No needles!

Safe

Rapid acting (30-60 secs)Very popular with parents and staff


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Intranasal Diamorphine

Dilute 10 mg of diamorphine powder with the specific volume of Water (gives 0.1 mg / kg in 0.2 ml)Prescribe as 0.1 mg/kg

Childs Weight Vol. Water

10 Kg 1.9 mls

15 Kg 1.3 mls

20 Kg 1.0 mls

25 Kg 0.8 mls

30 Kg 0.7 mls

35 Kg 0.6 mls

40 Kg 0.5 mls

50 Kg 0.4 mls

60 Kg 0.3 mls

Instil 0.2 mls of the solution into one nostril, using a 1-ml syringe, with the head tilted back


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Intranasal Diamorphine

1 ml syringe or mucosal

atomiser device

0.1 mg / kg

UK & Ireland

Onset < 1 min

Offset 40 mins

Refs Kendall J


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IN Fentanyl

Shown with mucosal atomiser

device

Commonly used Australasia,

South Africa, North America

No study directly comparing

IND / INF - probably similar

but INF is cheaper

Dose 1.7 mcg / kg

Onset < 1 min

Offset 40 mins

Refs Borland M and Mudd S


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Alternatives

IV morphine or

Cannula

Oramorph20 min onset

Watch this space:

Methoxyflurane


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Parenteral Midazolam (not IV)

A sedative, not an analgesic

PO / IN / buccal / rectal

Adequate sedation rates of approximately 61%

Paradoxical excitement in approximately 6%

Unpredictable, so lost popularity


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Procedural pain / distress

Common but tricky problem in EM

Conscious sedation now more correctly referred to

as Procedural sedation

Literature weighted towards critical care / post-op /palliative care / sedation for imaging: until last decade

Trained staff and full resus facilities and time needed


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Why would you need to give

procedural sedation?Same reasons as adults

Amnesia needed, for unpleasant procedure (eg

cardioversion)

Muscle relaxation needed (dislocations)

Different reasons from adults

More fear

Less reasoning (if you .. we can .. - and that will makeyou better)

Cooperation needed, for accuracy (eg suturing eyebrow)


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What is the best agent

for procedural sedation?Quote Davies F, Boston, Massachusetts, 1997

stupid question of the year award

Is there a magic bullet..?


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Requirements for ideal procedural agent

Sedation

Depression of awareness

Anxiolysis

Relief of trepidation/agitation

Amnesia

Lapse in memory

Analgesia

Relief of pain


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As well as:

Rapid onset

Short duration of action

Rapid offset with zero residual action

No haemodynamic effects

Easy to use and administer

Minimal contraindications

Well tolerated (i.e. minimal side-effects)


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Approach to PS have a checklist:

Have you minimised stress?

Have you minimised pain?

What is the procedure you want to do?

How long?

How still? (accuracy needed?

How painful?

How distressing?


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How long?


How painful?

How distressing?


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Anxiety re:

Unknowns

explanation to

child at one level

parent at another

Parent emotions -

Acknowledge

anxiety, blame,

surrounding accident

Anxiety re procedure

Anxiety re long term

effects of injury

Anxiety re staff skills (wedo this every day)


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Comfort zone

Environment separate from adult ED, murals and

other interior design features

Communication: being reassuring & listening tochildren, engaging parents childrens trained nurses

Preparation

demonstration

- limit waiting in anticipation


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Fingertip leaflet free from3M


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Play Specialists

Minority of EDs, even though more children attendED than paediatric wards/OPA!

Reasons: lack of awareness, lack of written evidenceof effectiveness, & boundary disputes over funding.Seen as fluffy bunny / icing on the cake / not core torequirement.

Top tip: they help you achieve the 4h target!


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Good staff

Nurses, doctors and Play Specialists / child life

specialists can do:

Preparation explanation, limit waiting in anticipationDistraction - DVD players, music, books, toys

Bargaining if necessary!

Reward - bravery certificates, sweets, trip toMcDonalds...........


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How long?


How painful?

How distressing?

BAEM Algorithm for treatment of acute pain in children in A&E


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Assess pain severityUse splints / slings / dressings etc

Consider other causes of distress*

For procedures consider regionalblocks and conscious sedation

MILD PAIN

Oral/rectal paracetamol20 mg/kg loading dose,

then 15 mg/kg4-6 hourlyand / or

Oral ibuprofen 10mg/kg 6-8 hourly

MODERATE PAINAs for mild pain

plus

oral/rectal diclofenac 1mg/kg 8 hourly (unlessalready had ibuprofen)

and / or

Oral codeine phosphate 1mg/kg 4-6 hourly if over 12

years old

SEVERE PAINConsider Entonox as holding

measurethen

Intranasal diamorphine 0.1 mls(see table)

followed by / orIV morphine 0.1-0.2 mg/kgbacked up by oral analgesics


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Analgesia

Sedatives are not analgesics your patient still

needs analgesia

Some analgesics also have sedative properties eg

opiates

Ie there is some crossover

Pure analgesics paracetamol, NSAIDs, topical

anaesthetic creams


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Topical Local Anaesthetic Mixtures

Low level of use within UK EDs; widespread use inAustralia and USA

Cochrane review June 2011: probably effective

problems with cocaine element, newer ones nococaine

Supply bit tricky: South Devon NHS Trust is onlysupplier


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COCAINE CONTAINING TOPICAL ANAESTHETICS

AC = Epinephrine-cocaine or Adrenaline-cocaine

MAC = Bupivacaine- epinephrine-cocaine or Bupivacaine-adrenaline-cocaine

TAC = Tetracaine-epinephrine-cocaine or Tetracaine adrenaline-cocaine

TC = Tetracaine Cocaine

COCAINE FREE TOPICAL ANAESTHETICS

BN = Bupivacaine-norepinephrine

EMLA = Eutectic mixture of local anaesthetics = lidocaine-prilocaineEN=Etidocaine-norepinephrine

LAT = LET = Lidocaine-epinephrine-tetracaine or Lidocaine-adrenaline-

tetracaine

LE = lidocaine-epinephrine or Lidocaine-adrenaline

MN= Mepivacaine-norepinephrine

PN = Prilocaine-norepinephrine PP = Prilocaine-phenylephrine

T = Tetracaine TE = Tetracaine-epinephrine or Tetracaine-adrenaline

TP = Tetracaine-phenylephrine

TLP = Tetracaine-lidocaine-phenylephrine


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Methoxyflurane

Penthrox inhaler

green whistle

Self administered

Aust & NZ

Onset < 1 min

Action 30 mins

Refs Babl F

No reported renal F

Trial in UK soon


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Procedural pain

Common but tricky problem in A&E

Conscious sedation now more correctly referred to

as Procedural sedation What is conscious? If your patient is still conversational are

they adequately sedated for the horrid things we do to them?

Trained staff and full resus facilities and time needed(4 hour target!)


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Requirements for ideal procedural agent

Sedation

Depression of awareness

Anxiolysis

Relief of trepidation/agitation

Amnesia

Lapse in memory

Analgesia

Relief of pain


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As well as:

Rapid onset

Short duration of action

Rapid offset with zero residual action

No haemodynamic effects

Easy to use and administer

Minimal contraindications

Well tolerated (i.e. minimal side-effects)


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Common procedures in ED

Pain

Distress

/ minimal

Patellar reduction

Elbow dislocation reduction

Foreign body ear canal

Earring stuck in lobe

Sutures

Trephine of subungualhaematoma

Foreign body protruding

(splinter, sewing needle)

/ minimal

Cannula (first ever) Head CT scan


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Drugs affecting consciousness

Minor effect

Inh Entonox

Chloral hydrate

IN diamorphineIN fentanyl

Methoxyflurane

More sedative

Ketamine

Propofol

KetofolNitrous oxide 70%

IV Fentanyl/midaz

IV Morphine/midaz


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Duration of action

QUICK

Inhaled Entonox 50%

IV Fentanyl/midaz

Intranasal diamorphine

Intranasal fentanyl

Inhaled Methoxyflurane

Sucrose PO (infants)

LONG

Inhaled Nitrous oxide 70%

IV Morphine/midaz

IV / IM Ketamine

chloral hydrate


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Why so much focus on distress and pain

doesnt sedation just sort both out?

Because stress and pain mean higher doses of sedative

AND

Sedation and analgesia are 2 different things

AND

Sedation may be avoided altogether if good skills in

stress and pain

So we often combine agents in practice


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Choice of agent

Mostly ketamine. Sometime IV morphine &midazolam or continuous nitrous oxide (need right setup) or propofol

Ketamine can be used orally but onset and offset tooslow for ED really

Fentanyl + midaz good for short procedures, if yourefamiliar with both drugs and inject slowly (chest wall

rigidity syndrome)Propofol has a narrow safety margin so only use ifyou have anaesthetic training


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Ketamine

(Special K on the street)

Safety profile and efficacy beyond reasonable doubt (Green SM

many refs) and better than any other PS agent

Complex mode of action, causing dissociative anaesthesia

(eyes are open but theres no-one at home)

High usage in US, Canada & Australia and ubiquitous in the

developing world; bit of a battle in UK

Helps prevent many admissions for general anaesthesia

Airway protected 990/1000 cases. Stridor / secretions respond

to simple repositioning in all cases. No respiratory depression


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Routes of administrationIV 1-2 mg/kg: onset 30s, offset 20m

IM 2-4 mg/kg: onset 30s, offset 45m

IN looks promising poss trial in the next year

Oral: onset 45 mins, offset 90m

Good to use supplemental local anaesthesia for

wounds

Atropine previously used to reduce secretions but nolonger recommended

Midazolam previously used to reduce emergence

reactions but no longer recommended


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Ketamine

So why the antipathy?

Unfortunately regarded as an anaesthetic agent by

UK anaesthetists and SIGN

Limited use in UK anaesthetic practice

Side-effect profile in adults (emergence

phenomenon)


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Discussion IV opiate / benzodiazepine

combinations

Fentanyl (1 mcg / kg) / midazolam (0.1 mg /

kg)

Chest wall rigidity syndromeMorphine (0.1 mg / kg)/ midazolam

Both effective

Fentanyl quicker onset and offset

Titrate to effect! Do not risk full anaesthesia


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Discussion - Propofol

Narrow window of dose for PS

Rapidly can become GA with drop in GCS

Gaining favour in adult EMAnyone brave enough in PEM?

Ketofol Shah et al, Ann Emerg Med.2011;57(5):425-33 0.5 mg/kg ketamine + 0.5 mg/kg

propofol: slightly shorter sedation time, recovery timeand vomiting 2% vs 12% for ketamine alone


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Back to our ED sedation agent

checklist..

Ketamine (for children) fulfils most of our criteria

Analgesia with some relaxation but preservation of

consciousness: opiate plus a little midazolam

Propofol also does well but more sensitive topic

than ketamine and needs further literature to

demonstrate safety in the non-anaesthetists hands


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Nitrous oxide

50% N2O / 50% O2 Entonox on demand valveuseable down to 4 years old Underrated

Useful in combination (eg local or intra-articular anaesthetic)

70% N2O via continous stream NB this is moderatesedation (next section) Refs Babl F

Mild to moderate pain (not severe)

Works well if IN fentanyl added in


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Considerations in procedural sedation

Peri-procedural patient assessment

Peri-procedural fasting?

MonitoringStaffing

Routine use of oxygen

Routine use of capnography?


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Safe Sedation Practice Documents

NICE guidelines on procedural sedation in children

2010

College of Emergency Medicine Guideline for

Ketamine Sedation of Children in Emergency

Departments, Sept 2009

www.collemergencymed.ac.uk
http://www.collemergencymed.ac.uk/http://www.collemergencymed.ac.uk/


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Peri-procedural Patient Assessment

Important to get pre-procedural health

Little evidence in literature on what clinical

parameters to look at

Avoid ex-ventilated patients, syndromic patients,

any funny looking airway or face

ASA classification system of physical status is used

by many to risk stratify patients before sedation


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Fasting

No evidence to support peri-procedural fasting times

Ketamine seems to show lowest rate of vomiting and

aspiration

CEM recommends There is no evidence that complications are reduced if thechild is fasted, however traditional anaesthetic practice favours a period of fasting prior to

any sedative procedure. The fasting state of the child should be considered in relation to the

urgency of the procedure, but recent food intake should not be considered as an absolute

contraindication to ketamine use.

ACEP 2008 recommendsProcedural sedation may be safely administered to pediatric patients in the ED who have

had recent oral intake.


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Fasting

UK National Institute for Clinical Excellence

guidelines use the 2, 4, 6 hour rule

2 hours post clear fluids

4 hours post milk

6 hours post food


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Monitoring

Observation

Probably most important talk to your patient

Sedation person should be different from treatment person

Oxygen saturations

Respiratory rate

Blood pressure

ECG

? CO2


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Routine use of Oxygen

2 schools of thought exist

Give oxygen as patients can become hypoxic

during sedation

Do not give oxygen as desaturation should warn

you of over sedation


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Exhaled CO2 Monitoring

Proving to be useful in assessing respiratory

depression in sedation

Pulse oximetry good for O2

Pulse oximetry useless for CO2

CO2 precedes O2 in respiratory depression

Measuring & spotting exhaled CO2 thereforeuseful early sign of respiratory depression


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Summary

Think of the whole patient / situation not just drugs

Safety is paramount

Use the CEM pain and ketamine guidelines andNICE PS guidelines

If you embark on procedural sedation, know therules, be safe, know your drugs, safe environment,training, audit

Make our EDs a happier place for our children


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Thank You

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