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.

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.

Spinal epidural abscess in preverbal children: A case report with Currarino triad.

Spinal epidural abscess is rare in preverbal children and leads to permanent neurologic deficits if not treated promptly. Currarino triad (anorectal malformation, sacral bony abnormality and presacral mass) is also rare in children. We report the association of extensive spinal epidural abscess and Currarino triad in a young child.

Etiology of septic arthritis in children: an update for the 1990s.

OBJECTIVE: To establish the etiology of septic arthritis in children after implementation of HIB immunization guidelines. METHODS: A retrospective review of all charts with a discharge diagnosis of septic arthritis (ICD-9: 711) from January 1991 to December 1996 at St. Louis Children's Hospital was conducted. RESULTS: Sixty-four patients (male = 58%) were identified, whose median age was 6.0 years. Twenty-one children (33%) were misdiagnosed on initial presentation. An organism was isolated in 38 (59%) of cases. The predominant organisms were Staphylococcus aureus (10 isolates), Group A Streptococcus (4), Enterobacter species (4), Kingella kingae (3), Neisseria meningitides (3), Streptococcus pneumoniae (2), Neisseria gonorrhoeae (2), Candida (2), Staphylococcus epidermidis (2). The only isolate of Haemophilus influenzae type B was in 1992 in an unimmunized 14 month old. CONCLUSIONS: These data confirm Staphylococcus aureus as a frequent pathogen and suggest that H influenzae type B is no longer the predominant isolate in young children with septic arthritis. In addition, early septic arthritis in children is frequently misdiagnosed on initial evaluation.

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.