Analgesia and Sedation in the Emergency Department

Dr Ffion Davies Consultant in Emergency Medicine

Acute Pain

Acute Pain
Very little high quality research exists on pain assessment tools and treatment of pain / sedation in Emergency Departments However pain is the main reason for attending the ED (eg. injuries, otitis media, abdominal pain)

Its not just the pain of the condition..

Situation drama Parents upset Fear of the injury itself Foreign environment

Fear of unknown what will happen to me?

Procedures / Rx may be painful

Dont forget the simple things

Non-pharmacological therapy

Splints clingfilm for burns etc

We need to use an appropriate pain assessment tool

This is the childs first time of using therefore has to be easy Has to be rough and ready due to time constraints & distractions

UK guideline and pain tools for ED use

College of Emergency Medicine Pain in children guideline July 2013

www.collemergencymed.ac.uk

Alder Hey Pain Tool (validated)

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed& pubmedid=15210492

Faces scales
Faces Pain Scale Faces Pain Scale-Revised Oucher pain scale

Wong-Baker Faces Pain Rating Scale

Similar inter-scale performance All flawed

BAEM Algorithm for treatment of acute pain in children in A&E

Assess pain severity Use splints / slings / dressings etc Consider other causes of distress* For procedures consider regional blocks and conscious sedation

MILD PAIN Oral/rectal paracetamol 20 mg/kg loading dose, then 15 mg/kg 4-6 hourly and / or Oral ibuprofen 10 mg/kg 6-8 hourly

SEVERE PAIN Consider Entonox as holding measure then Intranasal diamorphine 0.1 mls (see table) followed by / or IV morphine 0.1-0.2 mg/kg backed up by oral analgesics

MODERATE PAIN As for mild pain plus oral/rectal diclofenac 1 mg/kg 8 hourly (unless already had ibuprofen) and / or Oral codeine phosphate 1 mg/kg 4-6 hourly if over 12 years old

Parenteral analgesia
Inhaled, 1-2 doses (intranasal diamorphine / fentanyl or methoxyflurane)

Inhaled, continuous (N2O)

No needles! Safe Rapid acting (30-60 secs) Very popular with parents and staff

Intranasal Diamorphine
Dilute 10 mg of diamorphine powder with the specific volume of Water Prescribe as 0.1 mg/kg (gives 0.1 mg / kg in 0.2 ml)

Instil 0.2 mls of the solution into one nostril, using a 1-ml syringe, with the head tilted back
Childs Weight Vol. Water

10 Kg 15 Kg 20 Kg 25 Kg 30 Kg

1.9 mls 1.3 mls 1.0 mls 0.8 mls 0.7 mls

35 Kg
40 Kg 50 Kg

0.6 mls
0.5 mls 0.4 mls

60 Kg

0.3 mls

Intranasal Diamorphine
1 ml syringe or mucosal atomiser device 0.1 mg / kg UK & Ireland Onset < 1 min Offset 40 mins Refs Kendall J

IN Fentanyl
Shown with mucosal atomiser device Commonly used Australasia, South Africa, North America No study directly comparing IND / INF - probably similar but INF is cheaper Dose 1.7 mcg / kg Onset < 1 min Offset 40 mins Refs Borland M and Mudd S

Alternatives
IV morphine or

Cannula

Oramorph
20 min onset

Watch this space:

Methoxyflurane

Parenteral Midazolam (not IV)

A sedative, not an analgesic PO / IN / buccal / rectal Adequate sedation rates of approximately 61%

Paradoxical excitement in approximately 6%

Unpredictable, so lost popularity

Procedural pain / distress

Common but tricky problem in EM Conscious sedation now more correctly referred to as Procedural sedation Literature weighted towards critical care / post-op / palliative care / sedation for imaging: until last decade

Trained staff and full resus facilities and time needed

Why would you need to give procedural sedation?

Same reasons as adults

Amnesia needed, for unpleasant procedure (eg cardioversion) Muscle relaxation needed (dislocations)

Different reasons from adults

More fear Less reasoning (if you .. we can .. - and that will make you better) Cooperation needed, for accuracy (eg suturing eyebrow)

What is the best agent for procedural sedation?

Quote Davies F, Boston, Massachusetts, 1997 stupid question of the year award

Is there a magic bullet..?

Requirements for ideal procedural agent

Sedation

Depression of awareness Relief of trepidation/agitation

Anxiolysis

Amnesia

Lapse in memory
Relief of pain

Analgesia

As well as:

Rapid onset Short duration of action Rapid offset with zero residual action No haemodynamic effects

Easy to use and administer

Minimal contraindications Well tolerated (i.e. minimal side-effects)

Approach to PS have a checklist:

Have you minimised stress? Have you minimised pain? What is the procedure you want to do?

How long? How still? (accuracy needed?

How painful?
How distressing?

Approach to PS have a checklist:

Have you minimised stress? Have you minimised pain? What is the procedure you want to do?

How long? How still? (accuracy needed?

How painful?
How distressing?

Anxiety re:
Unknowns explanation to

Parent emotions Acknowledge

child at one level parent at another

anxiety, blame, surrounding accident Anxiety re procedure Anxiety re long term effects of injury Anxiety re staff skills (we do this every day)

Comfort zone
Environment separate from adult ED, murals and other interior design features

Communication: being reassuring & listening to children, engaging parents childrens trained nurses
Preparation
demonstration - limit waiting in anticipation

Fingertip leaflet free from 3M

Play Specialists
Minority of EDs, even though more children attend ED than paediatric wards/OPA!

Reasons: lack of awareness, lack of written evidence of effectiveness, & boundary disputes over funding. Seen as fluffy bunny / icing on the cake / not core to requirement.
Top tip: they help you achieve the 4h target!

Good staff
Nurses, doctors and Play Specialists / child life specialists can do:

Preparation explanation, limit waiting in anticipation

Distraction - DVD players, music, books, toys Bargaining if necessary! Reward - bravery certificates, sweets, trip to McDonalds...........

Approach to PS have a checklist:

Have you minimised stress? Have you minimised pain? What is the procedure you want to do?

How long? How still? (accuracy needed?

How painful?
How distressing?

BAEM Algorithm for treatment of acute pain in children in A&E

Assess pain severity Use splints / slings / dressings etc Consider other causes of distress* For procedures consider regional blocks and conscious sedation

MILD PAIN Oral/rectal paracetamol 20 mg/kg loading dose, then 15 mg/kg 4-6 hourly and / or Oral ibuprofen 10 mg/kg 6-8 hourly

SEVERE PAIN Consider Entonox as holding measure then Intranasal diamorphine 0.1 mls (see table) followed by / or IV morphine 0.1-0.2 mg/kg backed up by oral analgesics

MODERATE PAIN As for mild pain plus oral/rectal diclofenac 1 mg/kg 8 hourly (unless already had ibuprofen) and / or Oral codeine phosphate 1 mg/kg 4-6 hourly if over 12 years old

Analgesia
Sedatives are not analgesics your patient still needs analgesia Some analgesics also have sedative properties eg opiates

Ie there is some crossover

Pure analgesics paracetamol, NSAIDs, topical anaesthetic creams

Topical Local Anaesthetic Mixtures

Low level of use within UK EDs; widespread use in Australia and USA Cochrane review June 2011: probably effective problems with cocaine element, newer ones no cocaine Supply bit tricky: South Devon NHS Trust is only supplier

COCAINE CONTAINING TOPICAL ANAESTHETICS AC = Epinephrine-cocaine or Adrenaline-cocaine MAC = Bupivacaine- epinephrine-cocaine or Bupivacaine-adrenalinecocaine TAC = Tetracaine-epinephrine-cocaine or Tetracaine adrenaline-cocaine TC = Tetracaine Cocaine COCAINE FREE TOPICAL ANAESTHETICS BN = Bupivacaine-norepinephrine EMLA = Eutectic mixture of local anaesthetics = lidocaine-prilocaineEN= Etidocaine-norepinephrine LAT = LET = Lidocaine-epinephrine-tetracaine or Lidocaine-adrenalinetetracaine LE = lidocaine-epinephrine or Lidocaine-adrenaline MN= Mepivacaine-norepinephrine PN = Prilocaine-norepinephrine PP = Prilocaine-phenylephrine T = Tetracaine TE = Tetracaine-epinephrine or Tetracaine-adrenaline TP = Tetracaine-phenylephrine TLP = Tetracaine-lidocaine-phenylephrine

Methoxyflurane
Penthrox inhaler green whistle Self administered Aust & NZ Onset < 1 min Action 30 mins Refs Babl F No reported renal F Trial in UK soon

Procedural pain
Common but tricky problem in A&E Conscious sedation now more correctly referred to as Procedural sedation

What is conscious? If your patient is still conversational are they adequately sedated for the horrid things we do to them?

Trained staff and full resus facilities and time needed

(4 hour target!)

Requirements for ideal procedural agent

Sedation

Depression of awareness Relief of trepidation/agitation

Anxiolysis

Amnesia

Lapse in memory
Relief of pain

Analgesia

As well as:

Rapid onset Short duration of action Rapid offset with zero residual action No haemodynamic effects

Easy to use and administer

Minimal contraindications Well tolerated (i.e. minimal side-effects)

Approach to PS have a checklist:

Have you minimised stress? Have you minimised pain? What is the procedure you want to do?

How long? How still? (accuracy needed?

How painful?
How distressing?

Common procedures in ED
Pain Distress / minimal

Patellar reduction Elbow dislocation reduction Foreign body ear canal Earring stuck in lobe Sutures
Cannula (first ever)

Trephine of subungual haematoma Foreign body protruding (splinter, sewing needle)

Head CT scan

/ minimal

Drugs affecting consciousness

Minor effect Inh Entonox Chloral hydrate IN diamorphine IN fentanyl Methoxyflurane More sedative Ketamine Propofol Ketofol Nitrous oxide 70% IV Fentanyl/midaz IV Morphine/midaz

Duration of action
QUICK
Inhaled Entonox 50% IV Fentanyl/midaz Intranasal diamorphine Intranasal fentanyl Inhaled Methoxyflurane Sucrose PO (infants)

LONG
Inhaled Nitrous oxide 70% IV Morphine/midaz IV / IM Ketamine chloral hydrate

Why so much focus on distress and pain doesnt sedation just sort both out?
Because stress and pain mean higher doses of sedative AND Sedation and analgesia are 2 different things AND Sedation may be avoided altogether if good skills in stress and pain So we often combine agents in practice

Choice of agent
Mostly ketamine. Sometime IV morphine & midazolam or continuous nitrous oxide (need right set up) or propofol Ketamine can be used orally but onset and offset too slow for ED really Fentanyl + midaz good for short procedures, if youre familiar with both drugs and inject slowly (chest wall rigidity syndrome) Propofol has a narrow safety margin so only use if you have anaesthetic training

Ketamine
(Special K on the street) Safety profile and efficacy beyond reasonable doubt (Green SM many refs) and better than any other PS agent Complex mode of action, causing dissociative anaesthesia (eyes are open but theres no-one at home) High usage in US, Canada & Australia and ubiquitous in the developing world; bit of a battle in UK

Helps prevent many admissions for general anaesthesia

Airway protected 990/1000 cases. Stridor / secretions respond to simple repositioning in all cases. No respiratory depression

Routes of administration
IV 1-2 mg/kg: onset 30s, offset 20m IM 2-4 mg/kg: onset 30s, offset 45m IN looks promising poss trial in the next year Oral: onset 45 mins, offset 90m

Good to use supplemental local anaesthesia for wounds

Atropine previously used to reduce secretions but no longer recommended Midazolam previously used to reduce emergence reactions but no longer recommended

Ketamine
So why the antipathy? Unfortunately regarded as an anaesthetic agent by UK anaesthetists and SIGN Limited use in UK anaesthetic practice Side-effect profile in adults (emergence phenomenon)

Discussion IV opiate / benzodiazepine combinations

Fentanyl (1 mcg / kg) / midazolam (0.1 mg / kg)

Chest wall rigidity syndrome

Morphine (0.1 mg / kg)/ midazolam Both effective

Fentanyl quicker onset and offset

Titrate to effect! Do not risk full anaesthesia

Discussion - Propofol
Narrow window of dose for PS Rapidly can become GA with drop in GCS Gaining favour in adult EM Anyone brave enough in PEM?

Ketofol Shah et al, Ann Emerg Med. 2011;57(5):425-33 0.5 mg/kg ketamine + 0.5 mg/kg propofol: slightly shorter sedation time, recovery time and vomiting 2% vs 12% for ketamine alone

Back to our ED sedation agent checklist..

Ketamine (for children) fulfils most of our criteria

Analgesia with some relaxation but preservation of consciousness: opiate plus a little midazolam
Propofol also does well but more sensitive topic than ketamine and needs further literature to demonstrate safety in the non-anaesthetists hands

Nitrous oxide
50% N2O / 50% O2 Entonox on demand valve useable down to 4 years old

Underrated Useful in combination (eg local or intra-articular anaesthetic)

70% N2O via continous stream NB this is moderate sedation (next section)

Refs Babl F Mild to moderate pain (not severe) Works well if IN fentanyl added in

For simple cannulation

Sucrose solution 1ml (infants) Cochrane review seems effective

Sweet solution taste to ease injection needle pain in children aged one to 16 years Harrison D, Yamada J, Adams-Webber T, Ohlsson A, Beyene J, Stevens 2011

Considerations in procedural sedation

Peri-procedural patient assessment Peri-procedural fasting? Monitoring Staffing Routine use of oxygen Routine use of capnography?

Safe Sedation Practice Documents

NICE guidelines on procedural sedation in children 2010

College of Emergency Medicine Guideline for Ketamine Sedation of Children in Emergency Departments, Sept 2009 www.collemergencymed.ac.uk

Peri-procedural Patient Assessment

Important to get pre-procedural health Little evidence in literature on what clinical parameters to look at Avoid ex-ventilated patients, syndromic patients, any funny looking airway or face ASA classification system of physical status is used by many to risk stratify patients before sedation

Fasting
No evidence to support peri-procedural fasting times Ketamine seems to show lowest rate of vomiting and aspiration CEM recommends There is no evidence that complications are reduced if the
child is fasted, however traditional anaesthetic practice favours a period of fasting prior to any sedative procedure. The fasting state of the child should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as an absolute contraindication to ketamine use.

ACEP 2008 recommends

Procedural sedation may be safely administered to pediatric patients in the ED who have had recent oral intake.

Fasting
UK National Institute for Clinical Excellence guidelines use the 2, 4, 6 hour rule

2 hours post clear fluids

4 hours post milk 6 hours post food

Monitoring
Observation

Probably most important talk to your patient

Sedation person should be different from treatment person

Oxygen saturations Respiratory rate Blood pressure ECG

? CO2

Routine use of Oxygen

2 schools of thought exist Give oxygen as patients can become hypoxic during sedation Do not give oxygen as desaturation should warn you of over sedation

Exhaled CO2 Monitoring

Proving to be useful in assessing respiratory depression in sedation

Pulse oximetry good for O2

Pulse oximetry useless for CO2 CO2 precedes O2 in respiratory depression Measuring & spotting exhaled CO2 therefore useful early sign of respiratory depression

Summary
Think of the whole patient / situation not just drugs Safety is paramount Use the CEM pain and ketamine guidelines and NICE PS guidelines If you embark on procedural sedation, know the rules, be safe, know your drugs, safe environment, training, audit Make our EDs a happier place for our children

Thank You