Pain and Sedation: The Perspectives

of a Couple ED Fellows
Paria Wilson, MD
Adam Vukovic, MD
June 24, 2014

Outline
I. Procedures and Dissociative
Sedation
II. Rapid Sequence Intubation
III. Pain Management
IV. Sedation in the PICU

PART I: Procedures and

Dissociative Sedation

How are we doing with

pain?

Fein, J. A. (2010). Sedation and Analgesia. In G. R. Fleisher & S. Ludwig (Eds.), Textbook of Pediatric
4
Emergency Medicine (58-73). Philadelphia, PA: Lippincott Williams, Inc.

How will I address this

pain?

Fein, J. A. (2010). Sedation and Analgesia. In G. R. Fleisher & S. Ludwig (Eds.), Textbook of Pediatric
5
Emergency Medicine (58-73). Philadelphia, PA: Lippincott Williams, Inc.

I want to manage this

topically.
LET vs EMLA vs Ela-Max
LET: lidocaine, epinephrine, tetracaine
Where would you use this?
Where wouldnt you use this?

EMLA: eutectic mixture of local

anesthetics (lidocaine or prilocaine)
Where would you use this?

Ela-Max: lidocaine in a liposome

Where would you use this?
Fein, J. A. (2010). Sedation and Analgesia. In G. R. Fleisher & S. Ludwig (Eds.), Textbook of Pediatric
Emergency Medicine (58-73). Philadelphia, PA: Lippincott Williams, Inc.
Kundu, S., Achar, S. (2002). Principles of office anesthesia II: Topical anesthesia. American Family
6
Physician, Online. Available. http://www.aafp.org/afp/2002/0701/p99.html

I want to manage this

locally.
with injectable lidocaine

What is the maximum dose of 1%

lidocaine in a 10 kg child?
5 mg/kg X 10 kg = 50 mg; 10 mg/ml = 5
mL

What is the maximum dose of 1%

lidocaine with Epi in a 10 kg child?
7 mg/kg x 10 kg = 70 mg; 10 mg/mL =
Fein, J. A. (2010).
Sedation and Analgesia. In G. R. Fleisher & S. Ludwig (Eds.), Textbook of Pediatric
7
mL
7
Emergency Medicine (58-73). Philadelphia, PA: Lippincott Williams, Inc.

Nerve Block (digital block)

Indications:
Laceration involving nail or nail bed
Ingrown nails
Felon or paronychia
Trephination of subungual hematoma
Digit dislocation or fracture

Methods:
Web-space block
http://emedicine.medscape.com/article/80887-overview#a15

Flexor tendon sheeth block

Three- or four-sided ring block

Ketamine
What is dissociative sedation?
A trancelike cataleptic state induced by
the dissociative agent ketamine,
characterized by profound analgesia and
amnesia, with retention of protective
airway reflexes, spontaneous
respirations, and cardiopulmonary
stability.

So what do you say to parents?

Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Ketamine
Characteristics of the dissociative
state
Dissociation
Catalepsy
Analgesia
Amnesia
Maintenance of airway reflexes
Cardiovascular stability
Nystagmus
Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
10
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Ketamine
Short, painful procedures, especially
those requiring relative
immobilization:
Facial laceration
Burn debridement
Fracture reduction
Abscess I & D
Central line placement
Chest tube placement
Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
11
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Contraindications
Absolute

Relative

Age < 3 months

Known/suspected
schizophrenia
Pre
ti
a
d
se
on
se
n
o
c
nt

Major pharynx stimulation

(endoscopy)
H/o airway instability
Active pulmonary infection
or disease
Known or suspected cardiac
disease (CAD, CHF, HTN)
CNS masses, abnormalities,
or hydrocephalus
Porphyria or thyroid disease

Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
12
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Administration: General

Give as a single loading dose (IM vs IV)

Titration benefit?
Adverse effects related to dosing?
IV route preferred faster recovery
and less emesis
IV access not necessary in patients
who get IM ketamine (low risk of
adverse effects)
Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
13
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Administration: IV Route
1.5 to 2 mg/kg (children); 1.0 mg/kg
(adults)
Administer over 30-60 seconds
Re-dose at 0.5 to 1.0 mg/kg if
sedation is inadequate or repeat
doses are necessary for longer
procedures

Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
14
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Administration: IM Route
4-5 mg/kg (children); IV preferred in
adults
Repeat at full/half dose if inadequate
sedation in 5-10 minutes

Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
15
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Route of
Administration

IV

IM

Advantages

Ease of repeated
dosing; less
vomiting; slightly
faster recovery

No IV access
necessary

Peak [ ] and
clinical onset, min

Typical duration of
effective
dissociation, min

5-10

20-30

Typical time from

dose to discharge,
min

50-110

60-140

Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
16
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Co-administered
Medications
Prophylactic anticholinergic meds?
Prophylactic benzodiazepines?
Prophylactic ondansetron?
Local?
Suggests no, though we often do it
anyhow.

Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
17
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Procedure
AIRWAY!!!!
Monitoring?

Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
18
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Potential Adverse Effects

Large Meta-analysis:
3.9% of children had a reported
respiratory/airway complication
0.3% transient laryngospasm
Only associated with unusually high IV doses
Case control no association with age, dose,
oropharyngeal procedure, underlying illness, or route
Treat?

0.8% transient apnea

Unusual and nearly always transient
Seen with rapid IV push
Invariably at peak CNS concentration (1-2 min after dose)
Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
19
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

Potential Adverse Effects

Emesis (8.4%)
Peak in early adolescense
More frequent with IM vs IV
Late in recovery (and after d/c)

Recovery Reactions (6.3%, mild; 1.4%,

clinically significant)
Benzos help
Not related to age, dose or other factors to an
appreciable degree
Adolescents NOT at higher risk
Some association with pre-procedural agitation
Green, S. M., et al., Clinical practice guidelines for emergency department ketamine dissociative
20
sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461

PART II: Rapid Sequence

Intubation

21

Rapid Sequence Intubation

What is RSI?
Rapid induction of general anesthesia
that induces unconsciousness and
muscle relaxation to facilitate intubation

Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R.

Fleisher & S. Ludwig (Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: 22

Atropine:
- MOA: blocks the action of ACh
at parasympathetic sites
Lidocaine:
- Reduces ICP
- Reduces airway reactivity;
attenuates bronchospasm

Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R. Fleisher & S. Ludwig
23
(Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: Lippincott Williams, Inc.

Etomidate:
- Advantageous in broadest
range of RSI patients
- Rapid and reliable onset
- ICP reduction
- Cerebral metabolic demand
reduction
- Minimal CV depression (better
cerebral perfusion)
- Adverse effects:
- Myoclonus resembling SZ
- Suppresses glucocorticoid
and mineralocorticoid
levels

Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R. Fleisher & S. Ludwig
24
(Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: Lippincott Williams, Inc.

Ketamine:
- Rapid sedation, amnesia, and
analgesia
- Sympathetic stimulation
- Adverse reactions:
- Increased ICP???
- Intra-ocular pressure
elevation
- Excessive
secretions/laryngospasm
- Avoid in HTN, head injury
(+/-), psych patients,
glaucoma or open globe
injuries

Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R. Fleisher & S. Ludwig
25
(Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: Lippincott Williams, Inc.

Fentanyl:
- Short-acting opioid analgesic
- Less adverse effects than
morphine
- Chest wall rigidity with rapid
injection
- Naloxone
- Muscle relaxant
- Often used in CV surgery
- Less CV effect

Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R. Fleisher & S. Ludwig
26
(Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: Lippincott Williams, Inc.

RSI (other considerations)

Thiopental
Ultrashort-acting Barb
Previously one of the
most common used
Rapid onset (seconds)
Short duration
Cerebroprotective
Significant CV
depression
Induces bronchospasm

Propofol
Similar to
Thiopental in effect
Decreased ICP and
cerebral
metabolism
Rapid onset, brief
action
Can cause
significant CV
depression

Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R. Fleisher & S. Ludwig
27
(Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: Lippincott Williams, Inc.

RSI Sedative Selection

Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R. Fleisher & S. Ludwig
28
(Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: Lippincott Williams, Inc.

Succinylcholine:
- Depolarizing muscle
relaxant
- Rapid onset (30-60
seconds)
- Short duration (3-12
minutes)
- Can cause muscle
fasciculations
- Adverse effects:
- Negative
inotropy/chronotropy
- Malignant
hyperthermia
- Hyperkalemia
- HTN
- arrythmia
Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R. Fleisher & S. Ludwig
29
(Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: Lippincott Williams, Inc.

Rocuronium:
- Non-depolarizing agent
(fast)
- Fastest onset (30-90
sec)
- Shortest duration (2560 min)
- Minimal CV effect

Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation. In G. R. Fleisher & S. Ludwig
30
(Eds.), Textbook of Pediatric Emergency Medicine (74-84). Philadelphia, PA: Lippincott Williams, Inc.

Other Non-depolarizing
Agents
Vecuronium
RSI onset 90-120
sec
Can be faster in
high doses
Duration up to 2 hrs

Pancuronium

Atracurium
Faster onset
Histamine release
CV effects

Slower onset
More CV effects
31

PART III: PAIN

MANAGEMENT

32

Oooowwwieeee

33

34

Mild Pain

MEDICATIONTYLENOL IBUPROFEN IV
TYLENOL
(PO,PR)

DOSE
MOA

15mg/kg q4

10mg/kg q6

15mg/kg q6

?
InhibitsPG
release

NSAID
InhibitsPG
release

PROS

Analgesic,
Antipyretic

Analgesic,
Antipyretic

COX2- inhibition
?
?PGE2
production
Analgesic,
Antipyretic,
rapid
onset, NPO
patients

CONS

Hepatic injury

GI upset,
Hepatic injury
bleeding, cant
use in < 6mo

35

36

Moderate Pain
MEDICATION
OXYCODONETORADOL TRAMADOL
(IM,IV)

DOSE

5mg q4prn

15-30mg,
weight and age
based

2mg/kg q4

MOA

Opioid

NSAID
InhibitsPG
synthesis

Weak opioid,
SNRI

PROS

Acute and chronicKidney stones, Fibromyalgia,

pain, SCD,
Onc
migraines
chronic pain

CONS

Constipation, N/V,N/V, Bleeding, Urinary

retention,
apnea
AKI
N/V, ?sz
potential
(Goldstein, Berlin, Berkovitch, & Kozer, 2008)

37

38

Severe Pain
MEDICATION MORPHINE
(IM, IV)

DOSE

0.1 mg/kg

MOA

Opioid, CNS
depressant

PROS
CONS

FENTANYLHYDROMORPHONE
(IV,IN)
1mcg/kg IV
2mcg/kgIN

0.01mg/kg

Synthetic opioid Semi

synthetic opioid, acts
in CNS

Orthopedicinjuries, Fast acting, Fast acting, low histamine

biliary colic
sedation, safe
release
on BP
Respiratory
depression,
itchiness, ? BP

Rigid Chest

Respiratory depression

39

A few words about

Codeine
Converted to morphine
by P450 enzyme CYP2D6
Poor metabolizers: 515% population
Extensive
metabolizers: 75-92%
population
Ultra Rapid
metabolizers:
prevalence varies by
ethnic groups, up to 15%
in ME, N. Africans
(Racoosin, Roberson, Pacanowski, & Nielsen, 2013)

40

PART IV: SEDATION IN THE

PICU
All things that drip

41

Sedative Drips
MEDICATION

PRECEDEX

MIDAZOLAM

DOSE

0.20.7mcg/kg/
hr

1mg/kg/hr

MOA

2-agonist

PROS
CONS

Enhances GABA
action on GABA
receptors
No respiratory Anxiolysis, amnestic,
depression
antiepileptic
Dry mouth, ?HR,
?BP

Respiratory
depression, ?BP
42

References
www.ofirmev.com
www.micromedix.com
http://emedicine.medscape.com/article/80887-overview#a15
Fein, J. A. (2010). Sedation and Analgesia. In G. R. Fleisher & S. Ludwig (Eds.), Textbook
of Pediatric Emergency Medicine (58-73). Philadelphia, PA: Lippincott Williams, Inc.
Goldstein LH, Berlin M, Berkovitch M, Kozer E. Effectiveness of oral vs rectal
acetaminophen: a meta-analysis. Arch Pediatr Adolesc Med. 2008;162(11):1042-1046.
Green, S. M., et al., Clinical practice guidelines for emergency department ketamine
dissociative sedation: 2011 update. Annals of Emergency Medicine, 57(5), 449-461
Kundu, S., Achar, S. (2002). Principles of office anesthesia II: Topical anesthesia.
American Family Physician, Online. Available.
http://www.aafp.org/afp/2002/0701/p99.html
Racoosin JA, Roberson DW, Pacanowski MA, Nielsen DR. New evidence about an old
drug--risk with codeine after adenotonsillectomy. N Engl J Med. 2013;368(23):21552157.
Yamamoto, L. G. (2010). Emergency airway management: Rapid sequence intubation.
In G. R. Fleisher & S. Ludwig (Eds.), Textbook of Pediatric Emergency Medicine (74-84).
Philadelphia, PA: Lippincott Williams, Inc.
43