Petrack E, Perry LS, Vehar K.
 Integration of pharmacologic and non pharmacologic techniques to enhance pediatric minor procedures.
Jrnl Urgent Care Med. 2008 Feb; 2(5):11-16.
Children frequently require minor procedures, such as blood draws, IV catheter placement, suturing, and abscess drainage. Although "minor," these procedures can highlight safety concerns and create significant anxiety for the child, family and even staff. This article discusses how to gain trust, and give children and families a sense of control. Specific techniques are offered to position children for procedures to maximize safety and reduce restraint. The authors discuss how to use appropriate language, prepare, and then distract children during the procedure. The integration of pharmacologic and non-pharmacologic techniques is emphasized.
Zisk RY, Grey M, Medoff-Cooper B, MacLaren JE, Kain ZN.
The squeaky wheel gets the grease: parental pain management of children treated for bone fractures.
Pediatr Emerg Care. 2008 Feb;24(2):89-96.
This study looked at parental attitudes towards pharmacologic and non-pharmacologic pain management after extremity fractures. Fifty parents of children 5-10 years old with extremity fractures were studied. On the day following the fracture, 20% received no analgesia, and 44% received only 1 dose. Most children received analgesia based on active, loud behaviors such as crying; yet, children exhibited quiet behaviors more frequently than crying. Although this is a small number of patients, the authors raise the concern that recognizing behaviors that correlate with pain is difficult, and that quiet behaviors may also reflect pain and need for analgesia.
Borland, M., Jacobs, I., King, B., et al.
A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department.
Ann Emerg Med. 2007 Mar;49:335-340.
This was a prospective, randomized, double-blind, placebo-controlled trial comparing atomized intranasal fentanyl (mean 1.7 ug/kg) with intravenous morphine (mean 0.11 mg/kg) for pain associated with long bone fractures. 67 children were enrolled. There were no differences in pain visual analog scales at 5, 10, 20 or 30 minutes postanalgesia. It appears that intranasal fentanyl is as effective as intravenous morphine for acute fracture pain, and can be delivered more quickly and painlessly.
Ritsema TS, Kelen GD, Pronovost PJ et al.
The National Trend in Quality of Emergency Department Pain Management for Long Bone Fractures
Acad Emerg Med. 2007 Feb;14:163-169.
Although pain management continues to receive national attention, it is unclear how the JCAHO 2001 standards have impacted this important area. This is a retrospective study of the National Hospital Ambulatory Medical Care Survey (NHAMCS), comparing pain management for long bone fractures for the period before, and after, the new standards were implemented. Overall, analgesic use for this population increased from 56% to 76%, and opiate use increased from 50% to 56%. It appears that while there are increases in use of analgesics, there is still significant room for improvement.
Sacchetti A, Senula G, Strickland J et al.
Procedural sedation in the community emergency department: initial results of the ProSCED registry
Acad Emerg Med. 2007 Jan;14:41-4.6
There is little information on the use of procedural sedation in community emergency departments. This study examines 1,028 procedural sedations on 980 patients from 14 community ED study sites. Ages in this study ranged from 1 month to 95 years. A wide variety of sedating agents were used. Complications occurred in 4.1% of cases, with serious complications, such as assisted ventilation, occurring in 1.1% of cases. All complications were managed by the ED physician, and none required a change in disposition. They conclude that procedural sedation in the community ED setting appears to be safe and effective over a wide range of procedures and ages.
Drendel AL, Brousseau DC, Gorelick MH.
Pain assessment for pediatric patients in the emergency department.
Pediatrics 2006 May;117:1511-1518.
These authors examined the association between patient visit characteristics, pain score documentation, and analgesic use. Their data is based on the NHAMCS national survey (1997-2000), and included 24,707 visits. Younger age, self-pay, visits to pediatric facilities and non-injury visits were associated with decreased pain score documentation. Importantly, they found that documentation of pain score was associated with increased odds of analgesic (in particular, opioid) use. Overall, they conclude that infants and toddlers are at higher risk for not having pain score documentation, and that decreased documentation is associated with decreased analgesic use.
Sinha M, Christopher NC, Fenn R et al.
Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department.
Pediatrics. 2006 April;117:1162-1168.
This is the first controlled study to evaluate the effect of distraction techniques on children requiring laceration repair. While there are some limitations to this study, the authors found that distraction techniques reduced self-reported anxiety (but not pain) in older children and lowered parental perception of pain distress in younger children. It appears that the non pharmacologic techniques offered by child-life specialists and nurses may have an important role in this setting.
Stevenson MD, Bivins CM, O’Brien K et al.
Child life intervention during angiocatheter insertion in the pediatric
emergency department.
Ped Emerg Care. 2005 Nov;21:712-718.
There are very few studies which evaluate the role of child life specialists in the emergency department. This study focused
on children 2- 16 years of age, randomly assigning 149 children to a child life intervention or standard care. 121 of 149
patients (81%) required only one attempt at angiocatheter insertion, and in this group, there was a significant decrease in
behavioral distress, especially in children 4-7 years of age. This study supports the role of child life specialists in
preparing children for procedures.
Bijur PE, Kenny MK, Gallagher EJ.
Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute
pain in the majority of patients.
Ann Emerg Med. 2005 Oct;46:362-367.
Pain control for pediatric and adult patients is an essential component of both appropriate medical management and patient
satisfaction. Concerns with undertreatement of pain in emergency department patients has been well documented. In this study
of 119 adult patients who received 0.1 mg/ kg of intravenous morphine, only one-third achieved greater than 50% relief of
severe pain after 30 minutes. This study highlights the need to correctly reassess pain and titrate analgesic dosage to obtain
relief of pain.
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