You order a dose of intranasal fentanyl to be given immediately, while the nurses are placing an IV lock. Once your patient's pain is well controlled, X-ray of the right forearm is obtained. This demonstrates distal fractures of the radius and ulna not involving the growth plates with approximately 1 cm of overriding. You discuss procedural sedation with his parents and obtain consent. You administer IV fentanyl again for pain and then administer deep procedural sedation with propofol while the orthopedic specialist reduces the fracture and applies a sugartong splint. Post reduction films demonstrate near anatomic alignment of the fracture. He wakes up from sedation, takes some clear liquids and is discharged home in stable condition. Several days later, he follows up with orthopedics and a cast is placed.

Pain is a common chief complaint in pediatrics and is an undesirable side effect of many disease processes in children. The International Association for the Study of Pain defines pain as: "An unpleasant sensory and emotional experience associated with actual and potential tissue damage or described in terms of such damage." This definition demonstrates that pain encompasses both sensory and emotional components, which are even more important to recognize in the pediatric population. There are three commonly accepted categories of pain: somatic, visceral, and neuropathic. Somatic pain results from injury to tissues such as burns, lacerations or fractures. Somatic pain to superficial structures such as skin is usually sharp and well localized, where deep somatic pain due to fractures may be described as dull or aching and poorly localized. Visceral pain results from injury or inflammation to viscera, such as bowel distention, appendicitis, or constipation. This type of pain is notorious for being difficult to describe or localize by the patient and frequently may be referred to different locations. Neuropathic pain results from injury or inflammation to the peripheral or central nervous system, such as sciatica, Guillain-Barré syndrome, or phantom limb syndrome. Neuropathic pain may be described as electrical shocks, or "pins and needles" sensations or may involve hyperalgesia, hyperpathia, and allodynia (pain due to a stimulus that usually does not provoke pain). Pain is also an unfortunate side effect of many of the procedures or diagnostic studies performed to evaluate pediatric patients resulting in a great deal of anticipatory anxiety.

Assessment and Treatment of Pain

Historically, pediatric pain has an unfortunate tradition of being underassessed and undertreated. This is due to many factors, including the antiquated notion that children "tolerate pain well" or the concept of not treating pain because the practitioner doesn't want to "mask" the disease process. Numerous studies have demonstrated lower use of analgesics in children when compared to adults with similar disease processes. Many of us can recall observing circumcisions or lumbar punctures performed in years past on neonates without analgesia. Studies have shown that these painful experiences lead to greater pain responses when they were given their routine vaccinations.

Because pain is an individual experience and is subjective, it is best assessed in children using numerical scales such as the FLACC (faces, legs, activity, crying, consolability) score for younger children, the Oucher™ pain scale (1) or the Wong-Baker FACES® Pain Rating Scale (2). These scales have been validated, are well accepted by patients and are very useful for assessing the effectiveness of different interventions.

Treatment of pain includes nonpharmacologic and pharmacologic modalities which often overlap or may be combined for greater effect. Nonpharmacologic management includes biofeedback, guided imagery, hypnosis, and distraction. Many children's hospitals have child life teams that are very skilled in these practices. There is a robust literature for this field that is beyond the scope of this chapter, so the focus here will be pharmacologic pain management.

Topical Anesthetics

IV placement can be very traumatic for young children, but there are several options available to mitigate this painful experience. Ethyl Chloride spray "cold spray" has been shown to be effective for cryoanalgesia prior to IV placement, IM injection, or incision and drainage of small abscesses such as paronychia. Its use has decreased due to the adoption of other topical anesthetics such as EMLA® (eutectic mixture of local anesthetics) cream, LMX® or LET (lidocaine epinephrine, tetracaine) gel. EMLA® cream is a mixture of lidocaine and prilocaine. It is effective in reducing the pain of the venipuncture, IV placement or lumbar puncture. Disadvantages include requiring 60 minutes of application time to achieve maximal effect and vasoconstrictive effects that may make veins less visible. It should not be used in patients under 3 months old due to the possibility of methemoglobinemia. LMX® is a gel concentration of lidocaine, which is used in a similar manner as EMLA®. One advantage is that is works more quickly and may have similar analgesia after 20-30 of application. LET gel is a topical anesthetic made up of lidocaine, epinephrine, tetracaine. This is typically applied to open wounds, such as lacerations. If applied for 45-60 minutes, the analgesia is similar to injected lidocaine. If lidocaine injection is required, it will be less painful after the use of LET. Jet injection of lidocaine (J-tip®) has been widely adopted for IV placement in children. This system injects lidocaine subcutaneously utilizing a single use high pressure carbon dioxide cartridge. The analgesia affect is almost instantaneous and may be utilized for lumbar puncture as well. One disadvantage is that release of the cartridge makes a loud popping and then hissing sound, which may be scary for young children.

Local Anesthetics

The most widely used injectable anesthetic is 1% lidocaine (10 mg per mL) which is available with or without epinephrine. This is frequently used for procedures such as lumbar puncture, drainage of abscess, foreign body removal and wound repair. Maximum dosage of lidocaine is 5 mg per kilogram or 7 mg per kilogram when combined with epinephrine. Lidocaine provides excellent local anesthesia, which takes effect within several minutes and at lasts up to two hours; longer in combination with epinephrine. Historically, the use of lidocaine with epinephrine was contraindicated in areas with end arterial circulation such as digits, ears, and penis. Multiple studies have found that it is safe for injection into digits, allows for a smaller lidocaine dose, longer duration and avoids the vasodilatory effects of plain lidocaine. Lidocaine is very safe, but rare side effects have been reported when injected intravenously, including dysrhythmias, seizures, and cardiovascular collapse. The most common negative side effect of lidocaine is pain with injection, due to its acidic pH. This can be mitigated in several ways, including buffering with sodium bicarbonate in a 10:1 ratio, warming the solution, using a small needle (e.g., 30 or 27 gauge), injecting slowly through devitalized tissues, and rubbing the injection site prior to injection. There are other local anesthetics available including tetracaine, bupivacaine, and mepivicaine, all with longer durations of action. Regional nerve blocks may also be performed by experienced practitioners. In this procedure, a local anesthetic is deeply infiltrated adjacent to nerves, often under ultrasound guidance. The advantages of regional anesthesia include less tissue distortion, less anesthetic use and improved pain reduction. They do require a high degree of patient cooperation and there is a small risk of nerve damage.

Systemic Pain Medications

The World Health Organization (WHO) has an analgesic ladder to provide a stepwise approach according to pain severity. This was initially developed for children with cancer; however it can be applied in any patient with pain. It is also important to frequently reassess pain as well as response to different pain interventions. The WHO recommends acetaminophen or nonsteroidal anti-inflammatory drugs for mild pain, weak opioids for moderate pain and strong opioids such as morphine or fentanyl for severe pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and Acetaminophen

Acetaminophen is the most widely used analgesic and antipyretic in children. It is very well-tolerated and side effects are rare. Acetaminophen has no anti-inflammatory effects and its exact mechanism of action is unknown. The usual dose is 10 to 15 mg per kilogram given every 4 to 6 hours by mouth. It may also be given rectally 20 mg per kilogram every 4 to 6 hours. There is an IV formulation of acetaminophen, which was improved by the FDA in 2011. Explicit dosing parameters need to be discussed with caregivers because supratherapeutic dosing, especially in repeated doses, may lead to severe hepatotoxicity.

Nonsteroidal anti-inflammatory drugs work by inhibiting the COX (cyclooxygenase) pathway, thus preventing the formation of prostaglandin which is a mediator of pain, fever, and inflammation. Some studies have shown that NSAIDs are a more potent pain medication than acetaminophen and have a longer half-life. The most commonly utilized NSAID is ibuprofen and ketorolac is frequently utilized parenterally. The dosage of ibuprofen is 10 mg per kilogram per dose (max 600 to 800) every 6 to 8 hours and ketorolac is given 0.5 mg per kilogram per dose (max of 30 mg) every 6 hours. Ibuprofen is generally used for children over 6 months of age, but in Europe, it is used for children as young as 3 months old. IV ketorolac has been shown to as effective as morphine in postoperative pain, sickle cell crisis, and orthopedic injuries. It is also very effective for renal colic. There is an intravenous formulation of ibuprofen, which is indicated for PDA (patent ductus arteriosus) closure in neonates, but does not have an FDA indication for pain treatment. NSAIDs are well tolerated in children, however they do have antiplatelet effects, may cause gastrointestinal irritation, and there are case reports of renal failure, although these were self-limited.

Opioids

Opioids are utilized for patients with moderate to severe pain or for pain refractory to NSAIDs. Opiates refer to analgesics derived from the opium poppy, whereas opioids are synthetic substances with similar effects. The mechanism of action is interaction with opiate receptors of the central nervous system resulting in decreased levels of perceived pain. The term "narcotic" should be avoided when describing this class of medication because it confers negative cultural connotations. For moderate pain, oxycodone or hydrocodone may be given orally. This is much preferred to codeine. Codeine is a relatively weak agonist for the morphine receptor and is frequently nauseating. About one third of (or perhaps more) patients lack the enzyme to metabolize codeine into morphine essentially making it ineffective for them. Oxycodone and hydrocodone have similar efficacy, but hydrocodone is available only in combination with acetaminophen or ibuprofen. For severe pain, intravenous morphine and fentanyl are widely utilized and very effective. Morphine is initially dosed at 0.1 mg/kg per dose IV and fentanyl at 1 microgram/kg per dose IV or 2 micrograms/kg if given intranasally. Any patient administered opioids needs to be monitored for respiratory depression and hypotension, especially in younger patients or if sedative medication was given. Fentanyl has several advantages over morphine, including less hypotension, less histamine release, a shorter duration of action, and it may be given intranasally with similar effect. An uncommon but well documented side effect of fentanyl is severe chest rigidity, especially in infants, when given rapidly. Naloxone can be given to rapidly reverse the effects of opioid medications. Other less acute side effects are pruritus, constipation, nausea, vomiting, and urinary retention. Providers should be aware that patients with pain do not develop addiction to opioids in the acute setting as many patients and parents may be concerned about this. Patients admitted to the hospital with pain often benefit from patient controlled analgesia (PCA) devices which provide a low basal opioid infusion with intermittent patient activated boluses.

Unconventional Medications

There is a growing literature for many medications that were developed for a wide variety of different indications, but are now being found to have analgesic properties. These include some antiepileptic drugs, antidepressants, as well as neurotropic drugs. These are being increasingly used for neuropathic pain conditions, migraine headaches, chronic pain syndromes and fibromyalgia. Only a few of these medications have been approved by the FDA for treating pain syndromes in children. In general, these medications are not useful for somatic or musculoskeletal pain.

Procedural Sedation and Analgesia

The American College of Emergency Physicians defines procedural sedation and analgesia (PSA) as "Techniques of administering sedatives or dissociative agents with or without analgesia to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function." This term has replaced the term "conscious sedation", which was confusing and did not allow for differing levels of consciousness. PSA is seen as an integral part of pediatric emergency medical care as well as sedation services which provide support for lengthy radiology studies or hematology-oncology providers. There are four levels of PSA, which are summarized in the table below. Note that during deep sedation, airway and breathing may not be maintained. PSA must be considered as a continuum between these 4 levels and the physician administering the sedation must be credentialed, able to monitor the patient continuously, and respond if the patient is sedated more deeply than intended.

Level of Sedation	Patient will respond purposely to:	Airway / Breathing Maintained	Cardiovascular function maintained
Minimal Sedation	Verbal commands	Yes	Yes
Moderate Sedation	Light tactile stimulation	Yes	Yes
Deep Sedation	Painful stimulation	Potentially not	Yes
General Anesthesia	None	No	Potentially not

Table 1. Levels of PSA sedation. Adapted from AAP guidelines, Pediatrics 2006; 118:2587-2602

Pre-Sedation Evaluation

Prior to any sedation, a comprehensive history and physical is obtained, paying special attention to medical conditions, allergies, complications with prior sedations, snoring while sleeping, and last oral intake of food or liquid. History of upper airway infection in the preceding 1 to 2 weeks greatly increases airway reactivity during sedation. Elective procedures should be re-scheduled if the patient has a respiratory infection, due to this risk. Physical examination should focus on the airway, heart, and lungs. The airway should be examined for any conditions that may lead to airway compromise, e.g., small jaw, large tongue, loose teeth, or large tonsils. Patients are then assigned an American Society of Anesthesiologists (ASA) physical status classification (Table 2).

ASA Class	Description	Examples
I	Healthy, normal functioning patient	Unremarkable history
II	A patient with mild systemic disease (no functional limitations)	Mild asthma, anemia, well controlled seizure disorder
III	A patient with severe systemic disease (definite functional limitation)	Poorly controlled diabetes, moderate to severe asthma
IV	A patient with severe systemic disease that is a constant threat to life.	Severe bronchopulmonary dysplasia, sepsis
V	A moribund patient who is not expected to survive with or without surgery	Severe multisystem trauma, septic shock

Table 2. ASA Classes

Patients who are ASA class I or II are considered suitable candidates for minimal, moderate, or deep sedation. Patients who are ASA class III or above may require procedural sedation by a pediatric anesthesiologist, due to a higher risk of complication.

Fasting prior to Sedation

Procedural sedation may decrease airway reflexes and ideally, patients should be fasted prior to sedation to reduce the possibility of vomiting and aspiration. The ideal duration of fasting is under debate, although consensus based ASA guidelines advise the following: Fasting time of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for food, formula or cow's milk. Some institutions recommend an 8 hour fast for large meals. For patients who require emergency sedation, following these guidelines may not be possible. Multiple studies have shown no difference in the incidence of adverse events between those who have met fasting guidelines and those who have not. The American College of Emergency Physicians has a policy statement regarding this situation, which states "Recent food intake is not a contraindication for administering procedural sedation and anesthesia but should be considered in choosing the timing and target level of sedation."

Equipment and Monitoring

Age appropriate equipment needs to be available at the site of sedation. The American Academy of Pediatrics has a useful mnemonic for PSA preparation: SOAP ME (Table 3). End tidal CO2 monitoring should be added for procedures where chest rise cannot be directly monitored, such as MRI. Studies have shown that end tidal CO2 monitoring identifies hypoventilation prior to oxygen saturation dropping. Two trained providers should be present for every PSA, with one dedicated to the continuous monitoring of the patient while the other provider performs to the procedure.

S - Suction	Size appropriate suction catheters
O - Oxygen	Adequate supply of 100% oxygen and appropriate delivery devices
A - Airway	Oropharyngeal and naso-pharyngeal airways, equipment for bag mask ventilation, laryngoscope and intubation equipment
P - Pharmacy	Life support drugs as well as antagonists (naloxone, flumazenil)
M - Monitors	Pulse oximeter, blood pressure cuff, ECG, end-tidal CO2 monitor
E - Equipment	Special equipment as indicated

Table 3. PSA preparation. Adapted from AAP guidelines, Pediatrics 2006; 118:2587-2602

Pharmacologic Agents

When choosing the medications for PSA, there are several questions that must be considered. First of all, what is the goal of the sedation? Is it simply anxiolysis for a toddler with a deep forehead laceration that is being numbed with LET gel? Or is the procedure very painful, like a reduction of a fracture? Does the patient needed to be completely still, such as for an MRI of the brain or for a CT scan of the abdomen with IV contrast? What is the duration of the procedure? Would longer lasting agents be preferred or shorter acting agents which would allow for a shorter recovery time? In general, does the patient require anxiolysis, sedation, analgesia, or a combination of these? There are four general categories of agents utilized in PSA: Analgesics, sedative hypnotics, dissociative, and inhalational. There are a myriad of different medications and regimens for PSA. When pediatric emergency physicians were surveyed, they chose more than 20 different sedation strategies for post traumatic head CT in an uncooperative child. The full range of medications and regimens for PSA is beyond the scope of this chapter, so we will focus on some of the most useful medications: nitrous oxide, midazolam, ketamine, and propofol. The analgesics utilized in PSA are most frequently parental medications such as morphine and fentanyl as discussed in the medication section. As mentioned previously, when opioids are given in combination with sedatives, there is a much higher incidence of apnea or respiratory depression and the PSA provider needs to be vigilant in monitoring for this.

Nitrous oxide

Nitrous oxide is an inhalational agent utilized at many emergency departments as well as dental offices. It provides mild to moderate levels of analgesia, sedation, and dissociation (being unaware of the surrounding environment) when mixed with oxygen in concentrations between 30% and 70%. It can also induce euphoria, which is why it has been nicknamed "laughing gas". It has been used for years in dental offices, but is gaining greater acceptance in the pediatric emergency department. It is most useful for alleviating pain and distress for short invasive procedures. Examples of this would be IV placement, bladder catheterization, laceration repair, and abscess drainage. Local anesthetics are recommended for painful procedures, as the analgesic effects of nitrous oxide are quite modest. The main clinical advantage of nitrous oxide is very rapid onset and recovery, allowing the patient to be back at baseline status within several minutes. Adverse effects of nitrous oxide include nausea and vomiting in up to 10% of patients. Less commonly seen is restlessness, headache, and dysphoria. To be effective, the patient must be old enough to coordinate breathing with the nitrous oxide mask. Scavenger systems must be set up to prevent nitrous oxide release into the surrounding environment.

Midazolam

Midazolam, a benzodiazepine, is one of the most frequently used medications for pediatric PSA. It is potent sedative, amnestic, and anxiolytic, but lacks analgesic qualities. The mechanism of action of midazolam is interacting with GABA (gamma-amino butyric acid) receptors in the brain. It is more useful than other benzodiazepines, because it has a shorter half-life which makes it suitable for most procedures. Midazolam is also very versatile due to its water-soluble properties in that it can be given orally, intravenously, intranasally, or rectally. It is mostly used for anxiolysis in nonpainful procedures or with an analgesic for painful procedures. Administered by itself, it will provide anxiolytic effects for an uncooperative child, however, this will unlikely result in an immobile patient, making it less useful for longer imaging studies. The main side effects of midazolam include respiratory depression as well as hypotension. Rarely, there is a paradoxical reaction, where the patient becomes agitated and difficult to console. The side effects of midazolam may be reversed with flumazenil.

Ketamine

Ketamine is a dissociative agent, which provides profound sedation, analgesia, and amnesia. Patients who are administered ketamine will appear to be in a trance-like catatonic state unaware of the surrounding environment. The mechanism of action is to block excitatory amino acids on N-methyl D-aspartate receptors which are responsible for sensory perception, nociception, cognition and consciousness. Ketamine has been in use since the 1960s, but became much more popular during the 1990s. Ketamine is both lipophilic and water-soluble, allowing for administration via multiple routes, including orally, rectally, or intranasally. For PSA, intravenous or intramuscular administration are preferred. Ketamine is a very versatile agent due to its ability to provide rapid and reliable sedation, analgesia, and amnesia, while preserving cardiorespiratory function. It is most useful for short, painful procedures, where it can be given as a single agent either IV or IM. It is less useful for extended imaging studies, because the patient may continue to have some semi-purposeful movements during the sedation. Another agent, which lacks analgesic properties such as propofol would be more useful for this situation. As with any sedation agent, ketamine does have some shortcomings. Some of the side effects seen with ketamine are emergence reactions, post sedation nausea, and vomiting, hypersalivation, and less rarely laryngospasm. There are absolute contraindications and relative chronic indications for using ketamine. Absolute contraindications are age less than 3 months of age (too young to be dissociated, airway risk) and history of psychosis. Relative contraindications including procedures which stimulate the posterior pharynx, underlying cardiovascular disease including hypertension, or coronary artery disease, age between 3 months and 12 months. Historically, ketamine was contraindicated for conditions with increased cranial pressure or increased intraocular pressure. Recent studies indicate that this may not be clinically significant; however practitioners should probably use another agent rather than ketamine in these clinical settings. Emergence reactions and excessive salivation with ketamine have been studied in some depth. Emergence reactions include agitation, restlessness, active dreaming or hallucinations when emerging from sedation. This is more common in patients over 16 years of age, female patients or when larger doses of ketamine have been given. Historically, it was felt that giving midazolam with ketamine would reduce emergence reactions, but more recent studies do not support this. One strategy described in the literature involves telling your patient to "have nice dreams when you wake up". This seems to decrease the incidence of unpleasant emergence phenomenon. Excessive salivation is seen with ketamine and atropine or glycopyrrolate have a long been used to counteract this side effect. The literature does not support that adding these agents reduces the occurrence of associated adverse airway events; however they should be considered for procedures in which reducing oral secretions might be important, such as tongue laceration repair or peritonsillar abscess incision and drainage. There is a combination formulation of ketamine and propofol available (ketafol). Studies show that it seems to provide benefits in terms of shorter length of sedation time and lower incidence of vomiting due to propofol's antiemetic properties.

Propofol

Propofol is a highly lipid soluble, ultra short acting agent with pure sedative properties. It may only be administered via the intravenous route, either in boluses for short procedures or by infusion for longer procedures. It has been in use as an anesthetic agent since the 1970s. In 1999, it was first published for use in the pediatric emergency department for fracture reduction. Since that time, it has become an increasingly popular agent due to its very favorable qualities. When given along with an opioid, it provides excellent sedation for short, painful procedures such as fracture reduction or bone marrow aspiration. When administered by itself as an infusion, it is the agent of choice for sedating for long procedures, such as MRI or nuclear medicine studies. It can also be used for EEG sedation, but will cause EEG "fast" artifact at higher doses. Some institutions have policies that only anesthesiologists may use propofol, but multiple studies have demonstrated that pediatric emergency physicians can utilize this medication effectively and safely outside of the operating room. Side effects include transient respiratory depression and hypotension. In children, the hypotension is rarely clinically significant. Providers do need to be experienced when administering propofol, because it can impair airway reflexes and should be considered a general anesthetic agent. A burning sensation is often experienced by patients at the infusion site, but giving 0.5 mL to 1 mL of 1% lidocaine IV just prior to infusion can greatly reduce this. Propofol is given in 1 mg per kg boluses or as an infusion at 2 to 5 mg/kg/hr. Propofol is formulated in a soy emulsion with egg protein emulsifiers, so its use is contraindicated for patients with true egg or soy allergies. True egg allergy reaction to propofol is exceedingly rare. By 2011, only 5 case reports had been published that documented this type of reaction. Frequently providers are faced with parents who report that their child might have an egg or soy allergy. One case series evaluated this, with the conclusion that propofol is probably safe for these patients, unless they have had an anaphylactic reactions to eggs. Ultimately, this decision is up to the discretion of the sedation provider.

Discharge Criteria

Following sedation, patients are monitored for a minimum of 30 minutes and until several criteria are achieved. These include that the patient is awake, airway is maintained, able to talk and sit up (if developmentally appropriate), has normal vital signs, is tolerating clear liquids, and pain is well controlled. Parents or caregivers need to be instructed regarding ongoing monitoring and any possible complications of which to be aware.

Conclusion

Pain is a very common chief complaint for the children we care for and an unfortunate by-product of the tests or procedures that we order in caring for them. By being aware that pediatric pain is under-assessed and undertreated, we can be more vigilant in better treating the pain that our patients experience.

Questions

1. You are evaluating a 10 year old boy for abdominal pain and vomiting. He has focal tenderness to his right lower quadrant and is in obvious discomfort. You discuss with his parents that you are concerned about possible appendicitis and would like to place an IV, order some blood work and an ultrasound and consult pediatric surgery. What would be the most effective pain management strategy?
. . . . A. Administer a dose of ibuprofen orally.
. . . . B. Administer a dose of fentanyl intravenously.
. . . . C. Do not give pain medication, because you do not want to alter his exam.
. . . . D. Give a dose of intranasal midazolam.
. . . . E. Administer a dose of acetaminophen orally.

2. What is the maximum dose of 1% lidocaine, that can be infiltrated for wound repair in a 30 kg child which a very large laceration?
. . . . A. 1 mL
. . . . B. 5 mL
. . . . C. 10 mL
. . . . D. 15 mL
. . . . E. Lidocaine is contraindicated in children.

3. You are evaluating a febrile 3 month child who has a temperature of 40 degrees C, irritable, and has a stiff neck. You discuss performing a lumbar puncture (LP) to evaluate for meningitis. What would be the most appropriate strategy for reducing the pain of this procedure?
. . . . A. Don't provide any pain medication and hold the patient firmly during the procedure.
. . . . B. Apply LMX to the LP site and then infiltrate 1% lidocaine prior to procedure.
. . . . C. Administer a dose of ibuprofen orally and acetaminophen rectally prior to procedure.
. . . . D. Administer a dose of IM Ketamine prior to the procedure.
. . . . E. Administer nitrous oxide during the procedure.

4. A 12-year-old male presents to the ED with a painful sickle cell crisis. What is the important factor for assessing his pain?
. . . . A. The patient's verbal report.
. . . . B. His vital signs.
. . . . C. Parents report of his pain.
. . . . D. Teachers report of his pain.
. . . . E. Hospital records of prior sickle cell crisis treatment.

5. Which of the following medications has been shown to be safe and effective in treating pediatric pain when given via the intranasal route?
. . . . A. ibuprofen
. . . . B. acetaminophen
. . . . C. morphine
. . . . D. fentanyl
. . . . E. ketorolac

6. You are working in your hospitals sedation service and are evaluating an 8 year old child with history of seizures, well controlled on levetiracetam. He is scheduled for MRI of brain and EEG. His primary care provider evaluated him for the sedation 3 days ago and cleared him. After this, he developed a harsh cough, fever to 38.5 degrees and clear rhinorrhea. On exam, he does have rhinorrhea and course breath sounds. What would be the safest strategy when talking to his parents regarding the sedation?
. . . . A. Cancel the sedation and reschedule when he is well.
. . . . B. Proceed with the sedation as scheduled after discussing the risk and benefits.
. . . . C. Consult with anesthesiology.
. . . . D. Monitor him in the sedation room for several hours to see if his symptoms will resolve.

7. For the patient described in the prior scenario, if the patient had a normal exam and no antecedent upper respiratory infection, how would you rate his ASA classification?
. . . . A. ASA I
. . . . B. ASA II
. . . . C. ASA III
. . . . D. ASA IV
. . . . E. ASA V

8. Which of the following agents is considered a dissociative agent?
. . . . A. midazolam
. . . . B. propofol
. . . . C. fentanyl
. . . . D. acetaminophen
. . . . E. ketamine

References

1. www.wongbakerFACES.org

2. www.oucher.org

3. Uspal N, Black KD, Cico SJ. Pediatric Pain Management in the Emergency Department. Pediatric Emergency Medicine Practice 2012;9(12).

4. Zeltzer LK, Krane EJ. Chapter 71. Pediatric Pain Management. In: Kliegman, et al. (eds). Nelson Textbook of Pediatrics, 19th edition, 2011, Philadelphia: Mosby Elsevier, pp 360-375.

5. Fein JA, Selbst SM. Chapter 4. Sedation and Analgesia. In: Fleisher GR, Ludwig S. (eds). Textbook of Pediatric Emergency Medicine, 6th edition, 2010, Philadephia: Lippincott, Williams and Wilkins, pp. 58-74.

6. Matsuno WC, Ota FS. Managing Pediatric Procedural Pain and Anxiety in the Emergency Department. Pediatric Emergency Medicine Practice 2006;3(5).

7. Wetzel RC. Chapter 70. Anesthesia, Perioperative Care, and Sedation. In: Kliegman, et al. (eds). Nelson Textbook of Pediatrics, 19th edition, 2011, Philadelphia: Mosby Elsevier, pp. 359e1-e16.

8. Cote CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update. Pediatrics 2006;118(6):2587-2602.

9. Conners GP, Sacks WK, Leahey NF. Variations in Sedating Uncooperative, stable children for post-traumatic head CT. Pediatric Emergency Care 1999;15(4):241-244.

10. Kost S, Roy A. Procedural Sedation and Analgesia in the Pediatric Emergency Department: A Review of the Sedative Pharmacology. Clinical Pediatric Emergency Medicine 2010;11(4):233-243.

11. Caglar D, Kwun R. Pediatric Procedural Sedation and Analgesia in the Emergency Department. Pediatric Emergency Medicine Reports 2011;16(8).

12. Elikashvili I, Vella AE. An Evidence-Based Approach to Pediatric Procedural Sedation. Pediatric Emergency Medicine Practice 2012;9(8).

13. Koh JL, Palermo T. Conscious Sedation: Reality or Myth? Pediatrics in Review 2007;28:243-248.

14. Bennet J, DePiero A, Kost S. Tailoring Pediatric Procedural Sedation and Analgesia in the Emergency Department: Choosing a Regimen to Fit the Situation. Clinical Pediatric Emergency Medicine 2010;11(4):274-281.

15. Madati PJ. Ketamine: Pediatric Procedural Sedation in the Emergency Department. Pediatric Emergency Medicine Practice 2011;8(1).

16. Lopez MD, Beltran G. Pediatric Procedural Sedation. Pediatric Emergency Medicine Reports 2008;13(12).

17. Gorelick M, et al. Pediatric Sedation Pearls. Clinical Pediatric Emergency Medicine 2007;8:268-278.

18. Murphy A, et al. Allergic Reactions to Propofol in Egg-Allergic Children. Anesthesia and Analgesia 2011;113(1):140-144.

Answers to questions

1. B is the correct answer. Your patient is in significant pain and should be given an effective pain medication. Fentanyl would be the most effective choice. Ibuprofen or acetaminophen would not be as effective and you prefer to avoid oral medications, since he may require surgery and should be NPO. Midazolam does not have any analgesic qualities. Studies have evaluated this situation and found that pain medication does not significantly alter the exam and should not be withheld.

2. D is the correct answer. The maximum dose of lidocaine is 5 mg per kilogram body weight. 1% lidocaine contains 10 mg per mL. For a 30 kg child, 150 mg of lidocaine (5 mg per kg) could be infiltrated, which would be 15 mL. E is incorrect. Lidocaine is frequently utilized in children for wound repair or other procedure. Care should be taken not to inject lidocaine intravenously when infiltrating around the wound.

3. B is the correct answer. Lumbar punctures are very painful and all patients undergoing this procedure should have this pain ameliorated, so A is incorrect. Studies have shown that providing analgesia for LP, either topical or injected results in higher success rates. Ibuprofen and acetaminophen may be considered to treat the infant's fever, but would not provide adequate pain control, so C is incorrect. While ketamine is an effective pain medication, it is not recommended for use in patients three months old or younger. E is incorrect, because an infant is too young to utilize the nitrous oxide mask delivery system adequately.

4. A is the correct answer. For verbal children, their rating of the pain is in the most important factor in assessing their pain. There are multiple studies documenting that patients may be in significant pain without abnormal vital signs, making B incorrect. Because pain is subjective, teachers or parents report will be unreliable. Hospital records should be consulted to see what pain regimens were effective for prior sickle cell crisis, but these will be unhelpful for determining the patient's current pain level.

5. D is the correct answer. Fentanyl has been shown to be safe and effective in treating pediatric pain via the intranasal route. The other medications listed do not offer this advantage. While midazolam can be given intranasally, it does not have analgesic properties.

6. A is the correct answer. Patients with respiratory infection symptoms have increased risks of bronchospasm and laryngospasm during PSA. Elective procedures should be rescheduled in this situation. You could consider consulting anesthesiology, but they will agree with you.

7. B is the correct answer. A patient with well controlled seizures would be considered ASA II.

8. E is the correct answer. Ketamine is a dissociative agent that is in wide use for pediatric PSA.