Pain management and sedation for children in the emergency department
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4234 (Published 30 October 2009) Cite this as: BMJ 2009;339:b4234
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As consultant and registrar paediatric anaesthetists working in a
large university hospital with substantial paediatric attendance in the ED
we are concerned by some of the guidance offered specifically the use of
intravenous anaesthetic induction agents Ketamine, (and Propofol and
Midazolam) by ED doctors "appropriately trained" (our italics) in doses
(2mgs/kg for ketamine) sufficient to induce general anaesthesia in
unfasted children.
Health care commissionaires are now requesting specific data regarding
experience of anaesthetists treating children in acute trusts and some
anaesthetic departments are restricting paediatric care to those with
sufficient case load.
Our concern is that this review may be used as evidence that ED
doctors who have completed a sedation course (unspecified) may safely use
Ketamine (or Propofol, Midazolam with IV narcotics) on unfasted children
for fracture manipulations or suturing of facial lacerations. Recognition
of sick children and potential difficult airways requires experience.
.Even for those ED doctors who have received anaesthetic training,
paediatric exposure is usually limited and maintenance of practical skills
e.g. airway manipulation is an accepted problem. Unlike benzodiazepines
and narcotics there are no specific “antidotes” to Ketamine or Propofol.
All anaesthetists are aware that the international guidelines for
fasting (6 hours for food, 4 hours for breast milk and 2 hours for clear
fluids) may not guarantee an empty stomach especially in children with
trauma who have delayed gastric emptying. However the suggestion that
fasting is unnecessary based upon a 10 year old study of 257 procedures
during which no child suffered aspiration pneumonitis is brave.
Anaesthesia is remarkably safe in the UK today. Despite the
frustration caused by a six hour fast (breeching 4 hour ED stays?),
general anaesthesia with a protected airway, given by a specialist must
remain the safest option for many of these children.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
The authors need to be congratulated on clearing a lot of myth that
surrounds this topic. Emergency Medicine Specialists are constantly
drawing criticism from their paediatric colleagues and pharmacists who
consider a loading dose of 20mg/Kg for paracetamol as excessive, while the
authors quite correctly cite 30mg/Kg as a safe and effective initial dose.
Our pharmacy is currently trying to ban the 20mg/Kg dose used in nurse
triage. Sadly these misconcepts add to the reprehensible oligo-analgesia
that is so rife in acute pain in the emergency setting.
Unfortunately, the authors have omitted two important points.
Firstly, in relation to Morphine, they forget to specify that the
100mcg/Kg dose is a TARGET for IV titration and NOT a fixed 3 or 4 hourly
dose. Fixed dose of IV Morphine would cause either inadequate analgesia or
oversedation. The acutal dose titrated to response may well be below or
above this target.
Secondly, they make no mention of IM Ketamine given at 4mg/Kg as a
good alternative to IV Ketamine (Ref 1,2) for procedural sedation. At that
dose, the sedation is consistent, lasts long enough for most procedures
but may cause more vomiting. The college of emergency medicine has
recently published a guideline on paediatric sedation recommending 2mg/Kg
IM dose which is likely to provide inconsistent sedation needing a top-up
second dose.
Ref 1. Should I Give Ketamine IV or IM? Green SM, Krauss B. Annals of
Emergency Medicine 2006. 48(5):613-614.
Ref 2. A Randomized Controlled Trial of IV Versus IM Ketamine for
Sedation of Pediatric Patients Receiving Emergency Department Orthopedic
Procedures. Roback MG, Wathen JE, Mackenzie T, Bajaj L. Annals of
Emergency Medicine 2006. 48(5):605-612.
Competing interests:
None declared
Competing interests: No competing interests
Editor
The authors of this piece have offered a great deal of useful
information for hospital practitioners. May I be permitted to add a
handful of observations from primary care?
Individual children require individual management and then there is
the potentially confounding influence of parents. Much can be achieved in
the first few seconds of contact or, alternatively, your best efforts and
intentions can be ruined by the wrong first impressions.
If the practitioner at the instant of first contact is in the wrong
frame of mind (angry, upset, apprehensive, offended, tired, careless,
rushed...) the child will immediately be on guard and remain so. Take a
few seconds to gather yourself before opening the door. A confident, calm
and assured approach with a low pitched, relaxed tone of voice will win
many children over, even when they are in pain. If the child is conscious
and beyond the earliest stages of language development, always greet them
by name first and give your own name - and then greet the parent. A smile
will not always be appropriate; the appearance of sympathetic concern may
be called for. Emotional appropriateness is recognised at an early stage
of a child's development and the wrong affect can cause fear and worsen
suffering.
Would anyone in pain enjoy being peered down upon by an enormous
stranger in strange clothes? Get down on eye level with the child - sit or
kneel by the bed.
Parents and children can enter a cycle of mutually reinforcing
distress that can magnify the child's pain. Not all parents can master
their own emotions and supporting them is an important part of helping the
child. If the parent is in a state of great distress or anger it may help
both parent and child to attempt to allow them a few moments, at least,
apart. A cup of tea, a fag, a walk in the fresh air, phone relatives, an
opportunity for floods of tears, loo break, form filling... A female
member of staff will almost always be able to be an acceptable short term
substitute - no sexism intended; this is the way the world works. Parents
should be offered the choice of being present for painful procedures, give
them the benefit of the doubt about whether they can cope.
Giving the child something to do can help - hold the Entonox mask,
hold the cotton wool ball, put your finger on the knot, wipe those tears
away, blow your nose, lift this, press that, tell me about your
home/school/brother. Involving the child will build their confidence in
both you and themselves.
If the child asks 'Is this going to hurt?', and it is, then do not
lie. Say 'Yes' and, if necessary, add 'a little' or 'a lot'. Don't spring
a surprise on a child, tell them what is happening and when and where and
how and why.
Children know that sticking needles through the skin is going to
hurt.
Breastfed babies who do not require a 'nil by mouth' approach can be
put to the breast and will rarely notice the injection when well attached
and feeding. A knuckle or dummy to suck is second best. The BMJ had a
paper some years ago showing that sugared water was as effective as
paracetamol - if my memory serves.
In children (and adults) injections in any part of the body can be
made much less noticeable by firm local pressure or grip. Ask the child to
look away or the parent to clasp the child to them in a comforting manner.
In an upper arm injection (or small child's thigh), holding the entire
inner upper arm (or thigh) in your free hand, leaving the injection site
between your thumb and first finger, squeezing very firmly, holding the
pressure and then injecting will almost always result in an unnoticed
injection. My rationalisation of this is that firm hand/finger pressure is
understandably 'uncomfortable' and, by comparison, the needle prick is
trivial - is it distraction or is it some neurological gate mechanism
controlling adjacent nociceptive stimuli?
For abdominal wall injections (heparin, LHRH implants etc) taking a
firm generous handful of skin and fat in your free hand will create the
distracting stimulus, an immobile target and freedom from the risk of
painful rectus sheath perforation, all in one action.
Instinct, acumen and experience can eclipse the value of scoring
systems, frameworks, protocols and guidelines in practical patient
management at any age but in paediatrics they can make all the difference.
I pray that the numbers of grandparents who only now know how to suck
eggs is minimal and I offer my apologies to those who were already
familiar with the procedure.
Yours sincerely
Steve Ford
Competing interests:
None declared
Competing interests: No competing interests
To the Editor,
we greatly appreciated the paper by Atkinson et al about “Pain
management and sedation for children in the emergency department .”
- Even though, we believe that a major issue, which can be of significant
relevance in clinical practice has not been addressed. While we are well
aware of the fact that sedation without pain control is not a reasonable
goal we strongly support the use of intranasal midazolam, which is not
even mentioned in the paper, in many setting in the ER, in association
with adequate analgesia (1).
The evidence from the literature as well as our pragmatic everyday
experience suggest that intranasal midazolam via a MAD device (mucosal
atomization device) offers a major opportunity for a rapid onset (compared
to buccal administration which can be swallowed with a delayed onset or
spitted by an uncooperative child) of adequate sedation (1). Another issue
of major relevance in this setting is the one of midazolam dosage which is
usually reported in most experiences to be higher of the standard dosage
0.2 mg/kg, eg for intranasal administration 0.4-0.8 mg/kg (1).
From this point of view we make an exception also to the dosage reported
for oral midazolam in table 2, in which is reported a maximum dose of 5 mg
up to 10 years of age (2). A 10 year old child can weight more than 30
kilograms and we believe that a weight tailored dose would be more
appropriate in this setting.
1. Lane RD, Schunk JE. Atomized intranasal midazolam use for minor
procedures in the pediatric emergency department. Pediatr Emerg Care. 2008
May;24(5):300-3.
2. Borland M, Esson A, Babl F, Krieser D.Procedural sedation in children
in the emergency department: a PREDICT study. Emerg Med Australas. 2009
Feb;21(1):71-9.
Competing interests:
None declared
Competing interests: No competing interests
The clinical review by Atkinson, Chesters and Heinz made reference to
the
non-pharmacological methods of coping in paediatric pain relief in the
emergency department setting.[1] Twice in the article they mention the
role
of reassurance in reducing pain and distress for the child, once in the
context
of parental behaviour and once with regards to health care professional’s
behaviour. Whilst being a natural approach to a distressed child, it
should be
noted that many studies carried out in a number of different contexts
indicate
that reassurance to a child, particularly during invasive procedures, is
associated with increased anxiety, distress and pain in children.[2-6]
Thus,
health care professionals working in paediatric settings may have to be
more
aware that well meant verbalisations during procedures may not encourage
child coping. Whilst this might be a minor point, pain and distress is a
multifactorial phenomena,[7] and therefore all methods of potentially
decreasing child discomfort need to be utilised.
1. Atkinson P, Chesters A, Heinz P. Pain management and sedation for
children in the emergency department. BMJ 2009;339:b4234. (30 October.)
2. Chambers CT, Craig KD, Bennett SM. The impact of maternal behavior
on
children’s pain experiences: An experimental analysis. Journal of
Pediatric
Psychology 2002;27:293-301.
3. Manimala R, Blount, RL, Cohen LL. The effects of parental
reassurance
versus distraction on child distress and coping during immunizations.
Children’s Health Care 2000;29:161-177.
4. Schechter NL, Zempsky WT, Cohen, LL, McGrath, PJ, McMurtry, C,
Bright,
SN. (2007). Pain reduction during pediatric immunizations: Evidence-based
review and recommendations. Pediatrics 2007;119:1184-98.
5. Spagrud LJ, von Baeyer CL, Ali K, Mpofu C, Fennell LP, Friesen F,
et al. Pain,
distress and adult-child interaction during venepuncture in pediatric
oncology: An examination of three types of venous access. Journal of Pain
and
Symptom 2008;36:173-84.
6. Young KD. Pediatric procedural pain. Annals of Emergency Medicine
2005;45:160-71.
7. American Academy of Pediatrics. Committee on Psychosocial Aspects
of
Child and Family Health; Task Force on Pain in Infants, Children, and
Adolescents. The assessment and management of acute pain in infants,
children, and adolescents. Pediatrics. 2001;108:793-7.
Competing interests:
None declared
Competing interests: No competing interests
More on Pain management and sedation for children in the emergency department - Authors' reply
We would like to thank those who have responded to our article on
pain management and sedation for children in the emergency department.(1)
Crawford and Kapur have stated their concern regarding the widespread
use of “intravenous anaesthetic induction drugs” by appropriately trained
doctors, and also state that they believe a fasting time of six hours is
necessary for general anaesthesia. We clearly stated that general
anaesthesia is an alternative that should be considered, not an option to
be undertaken by emergency physicians. It is unfortunate that they have
failed to appreciate the advances made in the field of safe sedation in
emergency departments over the past two decades. This has now become
established practice and there is a growing body of evidence supporting
its safety when used appropriately.
There are a number of factors that have led to these developments
including cost pressures and admissions avoidance. Why admit every child
requiring a procedure for a general anaesthetic if the alternative is
timely, cost effective, more child friendly and at the same time safe?
Paediatric sedation in the emergency departments has been an evolving but
managed process which is reflected by the available guidance from
professional bodies.(2)
They mention international guidelines (without reference) for fasting
for six hours before general anaesthesia. There are however no guidelines
for sedation that recommend such a long period and there is increasing
recognition that the appropriate fasting time depends on a number of
factors including individual patient risk, urgency and target depth of
sedation. In particular for ketamine sedation, where airway reflexes are
protected, there is now good evidence to support much shorter fasting
times. An in depth discussion of these issues was beyond the scope of our
review and we recommend a recent review which addresses this in more
detail.(3)
We do agree with Crawford and Kapur that sedation in children should
be carried out by senior, appropriately trained doctors. Out of hours
consultant presence is commonplace in emergency departments – there is no
argument for leaving such procedures to unsupervised trainees who have not
proven their competence, whether they be from an emergency medicine or
anaesthetic background.
Thanks to Sen for highlighting some further issues with the dosing of
analgesia in the ED. We agree that appropriate doses must be used and that
titration to effect is important with opiates. Although intramuscular
Ketamine is an alternative to intravenous injection, its prolonged
recovery time due to the higher dose and the higher incidence of emesis
make it a lesser choice.(4) Arguably, children in whom intravenous access
cannot be easily obtained probably should not be sedated in the emergency
department.
De Cunto and colleagues highlight the use of intranasal midazolam.
Whilst we agree that there is evidence supporting its use, it does not
provide any analgesia, rather amnesia for painful procedures. It’s effects
are less predictable. We do recognise that it is an acceptable alternative
where intravenous access is difficult and where clinicians lack experience
with the use of drugs such as ketamine.
We believe we have provided an evidence-based approach that is
commonly used worldwide in EDs for the management of pain and provision of
safe sedation in children. We acknowledge that other approaches are also
in common use. We hope that all such approaches will lead to less pain for
children presenting to emergency departments.
1. Atkinson PR, Chesters a, Heinz P. Pain management and sedation for
children in the emergency department. BMJ 2009;339:b4234
2 . American College of Emergency Physicians. Clinical policy:
procedural sedation and analgesia in the emergency department. Ann Emerg
Med. 2005;45:177-196.
3. Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and
emergency department procedural sedation and analgesia: a consensus-based
clinical practice advisory. Ann Emerg Med. 2007 Apr;49(4):454-61
4. Green SM, Roback MG, Krauss B, Brown L, McGlone RG, Agrawal D,
McKee M, Weiss M, Pitetti RD, Hostetler MA, Wathen JE, Treston G, Garcia
Pena BM, Gerber AC, Losek JD; Emergency Department Ketamine Meta-Analysis
Study Group. Predictors of emesis and recovery agitation with emergency
department ketamine sedation: an individual-patient data meta-analysis of
8,282 children. Ann Emerg Med. 2009 Aug;54(2):171-80.
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