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Pharmacological Management of Pain and Anxiety During Emergency Procedures in Children

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Abstract

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.

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References

  1. Carr DB, Jacox AK, Chapman CR, et al. Acute pain management: operative or medical procedures and trauma. Rockville (MD): AHCPR Publication, 1992 Feb. Clinical practice guideline No. 1:92-0032

    Google Scholar 

  2. Schechter NL, Berde CB, Yaster M. Pain in infants, children, and adolescents. Baltimore (MD): Williams & Wilkins, 1993

    Google Scholar 

  3. Terndrup TE. Pediatric pain control. Ann Emerg Med 1996; 27: 466–70

    PubMed  CAS  Google Scholar 

  4. Walco GA, Cassidy RC, Schechter NL. Pain, hurt, and harm: the ethics of pain control in infants and children. N Engl J Med 1994; 331: 541–4

    PubMed  CAS  Google Scholar 

  5. Weisman SJ, Bernstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med 1998; 152: 147–9

    PubMed  CAS  Google Scholar 

  6. Zeltzer LK, Altman A, Cohen DM, et al. Report of the subcommittee on the management of pain associated with procedures in children with cancer. Pediatrics 1990; 86Suppl. 2: 826–34

    PubMed  CAS  Google Scholar 

  7. Committee on Drugs, American Academy of Pediatrics. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992; 89: 1110–5

    Google Scholar 

  8. Kennedy RM, Porter FL, Miller JP, et al. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics 1998; 102: 956–63

    PubMed  CAS  Google Scholar 

  9. Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med 1996; 3: 1086–92

    PubMed  CAS  Google Scholar 

  10. Luhmann JD, Kennedy RM, Porter FL, et al. Nitrous oxide regimens more effective than midazolam for reducing distress during laceration repair in young children [abstract]. Pediatr Res 1998; 43: 383A

    Google Scholar 

  11. Dollfus C, Annequin M, Adam M, et al. Analgesia with nitrous oxide for painful procedures in pediatric hematology-oncology. Ann Pediatr 1995; 42: 115–21

    Google Scholar 

  12. Selbst SM. Analgesia in children: why is it underused in emergency departments? Drug Saf 1992; 7: 8–13

    PubMed  CAS  Google Scholar 

  13. Friedland LR, Pancioli AM, Duncan KM. Pediatric emergency department analgesic practice. Pediatr Emerg Care 1997; 13: 103–6

    PubMed  CAS  Google Scholar 

  14. Krauss B, Zurakowski D. Sedation patterns in pediatric and general community hospital emergency departments. Pediatr Emerg Care 1998; 14: 99–103

    PubMed  CAS  Google Scholar 

  15. Pierluishi GJ, Terndrup TE. Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations. Pediatr Emerg Care 1989; 5: 211–5

    Google Scholar 

  16. Bonadio W. TAC:areview. Pediatr Emerg Care 1989; 5: 128–30

    PubMed  CAS  Google Scholar 

  17. Ernst AA, Marvez E, Nick TG, et al. Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years. Pediatrics 1995; 95: 255–8

    PubMed  CAS  Google Scholar 

  18. Schiling CG, Bank DE, Borchert BA, et al. Tetracaine, epinephrine (adrenalin), and cocaine (TAC) versus lidocaine, epinephrine, and tetracaine (LET) for anesthesia of lacerations in children. Ann Emerg Med 1995; 25: 203–8

    Google Scholar 

  19. Bonadio W. Safe and effective method for application of tetracaine, adrenaline, and cocaine to oral lacerations. Ann Emerg Med 1996; 28: 396–8

    PubMed  CAS  Google Scholar 

  20. Dailey RH. Fatality secondary to misuse of TAC solution. Ann Emerg Med 1988; 17: 159–60

    PubMed  CAS  Google Scholar 

  21. Wehner D, Hamilton GC. Seizures following topical application of local anesthetics to burn patients. Ann Emerg Med 1984; 13: 456–8

    PubMed  CAS  Google Scholar 

  22. Gajraj NM, Pennant JH, Watcha MF. Eutectic mixture of local anesthetics (EMLA®) cream. Anesth Analg 1994; 78: 574–83

    PubMed  CAS  Google Scholar 

  23. Bjerring P, Arendt-Nielsen L. Depth and duration of skin analgesia to needle insertion after topical application of EMLA® cream. Br J Anaesth 1990; 64: 173–7

    PubMed  CAS  Google Scholar 

  24. Michael A, Andrew M. The application of EMLA® and glyceryl trinitrate ointment prior to venepuncture. Anaesth Intensive Care 1996; 24: 360–4

    PubMed  CAS  Google Scholar 

  25. Teillol-Foo WLM, Kassab JY. Topical glycerl trinitrate and eutectic mixture of local anaesthetics in children. Anaesthesia 1991; 46: 881–4

    PubMed  CAS  Google Scholar 

  26. Doyle E, Freeman J, Im NT, et al. An evaluation of a new self-adhesive patch preparation of amethocaine for topical anaesthesia prior to venous cannulation in children. Anaesthesia 1993; 8: 1050–2

    Google Scholar 

  27. Van Kan HJM, Egberts ACG, Rijnvos WPM, et al. Tetracaine versus lidocaine-prilocaine for preventing venipuncture-induced pain in children. Am J Health Syst Pharm 1997; 54: 388–92

    PubMed  Google Scholar 

  28. Irsfeld S, Klement W, Lipfert P. Dermal anaesthesia: comparison of EMLA® cream with iontophoretic local anaesthesia. Br J Anaesth 1993; 71: 375–8

    PubMed  CAS  Google Scholar 

  29. Fradet C, McGrath PJ, Kay J, et al. A prospective survey of reactions to blood tests by children and adolescents. Pain 1990; 40: 53–60

    PubMed  CAS  Google Scholar 

  30. Krause RS, Moscati R, Filice M, et al. The effect of injection speed on the pain of lidocaine infiltration. Acad Emerg Med 1997; 4: 1032–5

    PubMed  CAS  Google Scholar 

  31. Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: rate of administration and buffering. Ann Emerg Med 1998; 31: 36–40

    PubMed  CAS  Google Scholar 

  32. Arndt KA, Burton C, Noe JM. Minimizing the pain of local anesthesia. Plast Reconstr Surg 1983; 72: 676–9

    PubMed  CAS  Google Scholar 

  33. Brogan GX, Giarrusso E, Hollander JE, et al. Comparison of plain, warmed, and buffered lidocaine for anesthesia of traumatic wounds. Ann Emerg Med 1995; 26: 121–5

    PubMed  Google Scholar 

  34. Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med 1998; 16: 353–6

    PubMed  CAS  Google Scholar 

  35. Christoph RA, Buchanan L, Begalia K, et al. Pain reduction in local anesthetic administration through pH buffering. Ann Emerg Med 1988; 17: 117–20

    PubMed  CAS  Google Scholar 

  36. McKay W, Morris R, Mushlin P. Sodium bicarbonate attenuates pain on skin infiltration with lidocaine, with or without epinephrine. Anesth Analg 1987; 66: 572–4

    PubMed  CAS  Google Scholar 

  37. Stanton-Hicks MD. Local anesthetics: pharmacology and clinical applications. Hosp Formul 1987; 22: 156–71

    Google Scholar 

  38. Bartfield JM, Homer PJ, Ford DT, et al. Buffered lidocaine as a local anesthetic: an investigation on shelf life. Ann Emerg Med 1991; 21: 16–9

    Google Scholar 

  39. Orlinsky M, Hudson C, Chan L, et al. Pain comparison of unbuffered versus buffered lidocaine in local wound infiltration. J Emerg Med 1992; 10: 411–5

    PubMed  CAS  Google Scholar 

  40. Meyer G, Henneman PL. Buffered lidocaine [letter]. Ann Emerg Med 1991; 20: 218–9

    PubMed  CAS  Google Scholar 

  41. Larson PO, Ragi G, Swandby M, et al. Stability of buffered lidocaine and epinephrine used for local anesthesia. J Dermatol Surg Oncol 1991; 7: 411–4

    Google Scholar 

  42. Task Force on Sedation and Analgesia by Non-Anesthesiologists, American Society of Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 1996; 84: 459–71

    Google Scholar 

  43. Maxwell LG, Yaster M. The myth of conscious sedation. Arch Pediatr Adolesc Med 1996; 150: 665–7

    PubMed  CAS  Google Scholar 

  44. Yaster M, Nichols DG, Deshpande JK, et al. Midazolam-fentanyl intravenous sedation in children: case report of respiratory arrest. Pediatrics 1990; 86: 463–7

    PubMed  CAS  Google Scholar 

  45. Schreiner MS. Preoperative and postoperative fasting in children. Pediatr Clin North Am 1994; 41: 111–20

    PubMed  CAS  Google Scholar 

  46. Warner MA, Warner ME, Warner DO, et al. Perioperative pulmonary aspiration in infants and children. Anesthesiology 1999; 90: 66–71

    PubMed  CAS  Google Scholar 

  47. Graff KJ, Kennedy RM, Jaffe DM. Conscious sedation for pediatric orthopaedic emergencies. Pediatr Emerg Care 1996; 12: 31–5

    PubMed  CAS  Google Scholar 

  48. Green SM, Rothrock SG, Lynch EL, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases. Ann Emerg Med 1998; 31: 688–97

    PubMed  CAS  Google Scholar 

  49. Pena BMG, Krauss B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 1999; 34: 483–91

    PubMed  CAS  Google Scholar 

  50. Strain JD, Harvey LA, Foley LC, et al. Intravenously administered pentobarbital sodium for sedation in pediatric CT. Radiology 1986; 161: 105–8

    PubMed  CAS  Google Scholar 

  51. Sanderson PM. A survey of pentobarbital sedation for children undergoing abdominal CT scans after oral contrast medium. Paediatr Anaesth 1997; 7: 309–15

    PubMed  CAS  Google Scholar 

  52. Fassler D, Wallace N. Children’s fear of needles. Clin Pediatr 1982; 21: 59–60

    Google Scholar 

  53. Humphrey GB, Boon CM, van den Heuvell GF, et al. The occurrence of high levels of acute behavioral distress in children and adolescents undergoing routine venipunctures. Pediatrics 1992; 90: 87–91

    PubMed  CAS  Google Scholar 

  54. Lewis N. The needle is like an animal: how children view injections. Child Today 1978; 7: 18–21

    PubMed  CAS  Google Scholar 

  55. Rice LJ. Needle phobia: an anesthesiologist’s perspective. J Pediatr 1993; 122 (5 Pt 2): S9–13

    PubMed  CAS  Google Scholar 

  56. Eland JM, Anderson JE. The experience of pain in children. In: Jacox A, editor. A source book for nurses and other health professionals. Boston (MA): Little, Brown, 1977: 453–76

    Google Scholar 

  57. Dennis AR, Leeson-Payne CG, Langham BT, et al. Local anesthesia for cannulation: has practice changed? Anaesthesia 1995; 50: 400–2

    PubMed  CAS  Google Scholar 

  58. Klein EJ, Shugerman RP, Leigh-Taylor K, et al. Buffered lidocaine: analgesia for intravenous line placement in children. Pediatrics 1995; 95: 709–12

    PubMed  CAS  Google Scholar 

  59. Sacchetti A, Carraccio C. Subcutaneous lidocaine does not affect the success rate of intravenous access in children less than 24 months of age. Acad Emerg Med 1996; 3: 1016–9

    PubMed  CAS  Google Scholar 

  60. Wolfram RW, Turner ED. Effects of parental presence during children’s venipuncture. Acad Emerg Med 1996; 3: 58–64

    PubMed  CAS  Google Scholar 

  61. Bauchner H, Vinci R, Bak S, et al. Parents and procedures: a randomized controlled trial. Pediatrics 1996; 98: 861–7

    PubMed  CAS  Google Scholar 

  62. Wolfram RW, Turner ED, Philput C. Effects of parental presence during young children’s venipuncture. Pediatr Emerg Care 1997; 13: 325–8

    PubMed  CAS  Google Scholar 

  63. Fernald CD, Corry JJ. Emphatic versus directive preparation of children for needles. Child Health Care 1981; 10: 44–7

    PubMed  CAS  Google Scholar 

  64. Maunuksela EL, Korpela R. Double-blind evaluation of a lignocaine-prilocaine cream (EMLA®) in children. Br J Anaesth 1986; 58: 1242–5

    PubMed  CAS  Google Scholar 

  65. Arts SE, Abu-Saad HH, Champion GD, et al. Age-related response to lidocaine-prilocaine (EMLA®) emulsion and effect of music distraction on the pain of intravenous cannulation. Pediatrics 1994; 93: 797–801

    PubMed  CAS  Google Scholar 

  66. Lawson RA, Smart NG, Gudgeon AC, et al. Evaluation of an amethocaine (tetracaine) gel preparation for percutaneous analgesia before venous cannulation in children. Br J Anaesth 1995; 75: 282–5

    PubMed  CAS  Google Scholar 

  67. Zempsky WT, Anand KJS, Sullivan KM, et al. Lidocaine iontophoresis for topical anesthesia before intravenous line placement in children. J Pediatr 1998; 132: 1061–3

    PubMed  CAS  Google Scholar 

  68. Soliman IE, Broadman LM, Hannallah RS, et al. Comparison of the analgesic effects of EMLA® to intradermal lidocaine infiltration prior to venous cannulation in unpremedicated children. Anesthesiology 1988; 68: 804–6

    PubMed  CAS  Google Scholar 

  69. Fein JA, Boardman CR, Stevenson S, et al. Saline with benzyl alcohol as intradermal anesthesia for intravenous line placement in children. Pediatr Emerg Care 1998; 14: 119–22

    PubMed  CAS  Google Scholar 

  70. Luhmann JD, Shootman M, Kennedy RM. Making ivs ouch-less: buffered lidocaine versus benzyl alcohol [abstract]. Ped Res 2000; 47: 113A

    Google Scholar 

  71. Henderson JM, Spence DG, Komocar LM, et al. Administration of nitrous oxide to pediatric patients provides analgesia for venous cannulation. Anesthesiology 1990; 72: 269–71

    PubMed  CAS  Google Scholar 

  72. Vetter TR. A comparison of EMLA® crean versus nitrous oxide for pediatric venous cannulation. J Clin Anesth 1995; 7: 486–90

    PubMed  CAS  Google Scholar 

  73. Brislin RP, Stayer SA, Schwartz RE, et al. Analgesia for venepuncture in a paediatric surgery centre. J Pediatr Child Health 1995; 31: 542–4

    CAS  Google Scholar 

  74. Kennedy RM, Luhmann JD. The ouchless emergency department. Getting closer. Advances in decreasing distress during painful procedures in the emergency department. Pediatr Clin North Am 1999; 46: 1215–47

    PubMed  CAS  Google Scholar 

  75. Burton JH, Auble TE, Fuchs SM. Effectiveness of 50% nitrous oxide/50% oxygen during laceration repair in children. Acad Emerg Med 1998; 5: 112–7

    PubMed  CAS  Google Scholar 

  76. Fatovich DM, Jacobs IG. A randomized, controlled trial of oral midazolam and buffered lidocaine for suturing lacerations in children (the SLIC Trial). Ann Emerg Med 1995; 25: 209–14

    PubMed  CAS  Google Scholar 

  77. Qureshi FA, Mellis PT, McFadden MA. Efficacy of oral ketamine for providing sedation and analgesia to children requiring laceration repair. Pediatr Emerg Care 1995; 11: 93–7

    PubMed  CAS  Google Scholar 

  78. Yamamoto LG, Young LL, Roberts JL. Informed consent and parental choice of anesthesia and sedation for the repair of small lacerations in children. Am J Emerg Med 1997; 15: 285–9

    PubMed  CAS  Google Scholar 

  79. Bruns TB, Simon HK, McLario DJ, et al. Laceration repair using a tissue adhesive in a children’s emergency department. Pediatrics 1996; 98: 673–5

    PubMed  CAS  Google Scholar 

  80. Bruns TB, Robinson BS, Smith RJ, et al. A new tissue adhesive for laceration repair in children. J Pediatr 1998; 132: 1067–70

    PubMed  CAS  Google Scholar 

  81. Simon HK, McLario DJ, Bruns TJ, et al. Long-term appearance of lacerations repaired using a tissue adhesive. Pediatrics 1997; 99: 193–5

    PubMed  CAS  Google Scholar 

  82. Zempsky WT, Karasic RB. EMLA® versus TAC for topical anesthesia of extremity wounds in children. Ann Emerg Med 1997; 30: 163–6

    PubMed  CAS  Google Scholar 

  83. Bartfield JM, Sokaris SJ, Raccio-Robak N. Local anesthesia for lacerations: pain of infiltration inside vs outside the wound. Acad Emerg Med 1998; 5: 100–4

    PubMed  CAS  Google Scholar 

  84. Trott A. Wounds and lacerations: emergency care and closure. 2nd ed. St Louis (MO): Mosby, 1999

    Google Scholar 

  85. Ghoneim MM, Mewaldt SP. Benzodiazepines and human memory: a review. Anesthesiology 1990; 2: 926–38

    Google Scholar 

  86. Ramoska EA, Linkenheimer R, Glasgow C. Midazolam use in the emergency department. J Emerg Med 1991; 9: 247–51

    PubMed  CAS  Google Scholar 

  87. Wright SW, Chudnofsky CR, Dronen SC, et al. Comparison of midazolam and diazepam for conscious sedation in the emergency department. Ann Emerg Med 1993; 201–5

    Google Scholar 

  88. Hennes HM, Wagner V, Bonadio W, et al. The effect of oral midazolam on anxiety of preschool children during laceration repair. Ann Emerg Med 1990; 19: 1006–9

    PubMed  CAS  Google Scholar 

  89. Connors K, Terndrup TE. Nasal versus oral midazolam for sedation of anxious children undergoing laceration repair. Ann Emerg Med 1994; 24: 1074–9

    PubMed  CAS  Google Scholar 

  90. Shane SA, Fuchs SM, Khine H. Efficacy of rectal midazolam for the sedation of preschool children undergoing laceration repair. Ann Emerg Med 1994; 24: 1065–73

    PubMed  CAS  Google Scholar 

  91. Doyle WL, Perrin L. Emergence delirium in a child given oral midazolam for conscious sedation. Ann Emerg Med 1994; 24: 1173–5

    PubMed  CAS  Google Scholar 

  92. Schechter NL, Weisman SJ, Rosenblum M, et al. The use of oral transmucosal fentanyl citrate for painful procedures in children. Pediatrics 1995; 95: 335–9

    PubMed  CAS  Google Scholar 

  93. Schutzman SA, Burg J, Liebelt E, et al. Oral transmucosal fentanyl citrate for premedication of children undergoing laceration repair. Ann Emerg Med 1994; 24: 1059–64

    PubMed  CAS  Google Scholar 

  94. Schutzman SA, Liebelt E, Wisk M, et al. Comparison of oral transmucosal fentanyl citrate and intramuscular meperidine, promethazine, and chlorpromazine for conscious sedation of children undergoing laceration repair. Ann Emerg Med 1996: 18: 385–90

    Google Scholar 

  95. Bates BA, Schutzman SA, Fleisher GR. A comparison of intranasal sufentanil and midazolam to intramuscular meperidine, promethazine, and chlorparomazine for conscious sedation in children. Ann Emerg Med 1994; 24: 646–51

    PubMed  CAS  Google Scholar 

  96. Gutstein HB, Johnson KL, Heard MB, et al. Oral ketamine preanesthetic medication in children. Anesthesiology 1992; 76: 28–33

    PubMed  CAS  Google Scholar 

  97. Tobias JD, Phipps S, Smith B, et al. Oral ketamine premedication to alleviate the distress of invasive procedures in pediatric oncology patients. Pediatrics 1992; 90: 537–41

    PubMed  CAS  Google Scholar 

  98. Luhmann JD, Kennedy RM, Porter FL, et al. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair. Ann Emerg Med 2001; 37(1): 20–7

    PubMed  CAS  Google Scholar 

  99. Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med 1989; 18: 177–81

    PubMed  CAS  Google Scholar 

  100. Luhmann JD, Kennedy RM, Jaffe DM, et al. Continuous flow delivery of nitrous oxide and oxygen: a safe and cost effective technique for inhalation analgesia and sedation of pediatric patients. Pediatr Emerg Care 1999; 15: 388–92

    PubMed  CAS  Google Scholar 

  101. Quinn M, Carraccio C, Sacchetti A. Pain, punctures, and pediatricians. Pediatr Emerg Care 1993; 9: 12–4

    PubMed  CAS  Google Scholar 

  102. McGrath PJ, McAlpine L. Psychologic perspectives on pediatric pain. J Pediatr 1993; 122 (5 Pt 2): S2–8

    PubMed  CAS  Google Scholar 

  103. Pinheiro JM, Furdon S, Ochoa LF. Role of local anesthesia during lumbar puncture in neonates. Pediatrics 1993; 91:379–82

    PubMed  CAS  Google Scholar 

  104. Porter FL, Miller JP, Cole FS, et al. A controlled trial of local anesthesia for lumbar punctures in newborns. Pediatrics 1991; 88: 663–9

    PubMed  CAS  Google Scholar 

  105. Gimenez JC, Oliveras M, Hidalgo E, et al. Anesthetic efficacy of eutectic prilocaine-lidocaine cream in pediatric oncology patients undergoing lumbar puncture. Ann Pharmacother 1996; 30: 1235–7

    CAS  Google Scholar 

  106. Kapelushnik J, Koren G, Solh H, et al. Evaluating the efficacy of EMLA® in alleviating pain associated with lumbar puncture: comparison of open and double-blinded protocols in children. Pain 1990; 42: 31–4

    PubMed  CAS  Google Scholar 

  107. Freyer DR, Schwanda AE, Dominic JS, et al. Intravenous methohexital for brief sedation of pediatric oncology outpatients: physiologic and behavioral responses. Pediatrics 1997; 99: E8

    PubMed  CAS  Google Scholar 

  108. Friedman AG, Mulhern RK, Fairclough D, et al. Midazolam premedication for pediatric bone marrow aspiration and lumbar puncture. Med Pediatr Oncol 1991; 19: 499–504

    PubMed  CAS  Google Scholar 

  109. Committee on Drugs, American Academy of Pediatrics. Reappraisal of lytic cocktail/demerol, phenergan, and thorazine (DPT) for the sedation of children. Pediatrics 1995; 95:598–602

    Google Scholar 

  110. Hennrikus WL, Shin AY, Klingelberger CE. Self-administered nitrous oxide and a hematoma block for analgesia in the outpatient reduction of fractures in children. J Bone Joint Surg Am 1995; 77: 335–9

    PubMed  CAS  Google Scholar 

  111. Meinig RP, Quick A, Lobmeyer L. Plasma lidocaine levels following hematoma block for distal radius fractures. J Orthop Trauma 1989; 3: 187–91

    PubMed  CAS  Google Scholar 

  112. Bolte R, Stevens P, Scott S, et al. Mini-dose bier block intravenous regional anesthesia in emergency department treatment of pediatric upper-extremity injuries. J Pediatr Orthop 1994; 4: 534–7

    Google Scholar 

  113. Juliano PJ, Mazur JM, Cummings RJ, et al. Low-dose lidocaine intravenous regional anesthesia for forearm fractures in children. J Pediatr Orthop 1992; 12: 633–5

    PubMed  CAS  Google Scholar 

  114. Cramer KE, Glasson S, Mencio G, et al. Reduction of forearm fractures in children using axillary block anesthesia. J Orthop Trauma 1995; 9: 407–10

    PubMed  CAS  Google Scholar 

  115. Green S, Johnson NE. Ketamine sedation for pediatric procedures: part 2, review and implications. Ann Emerg Med 1990; 19: 1033–46

    PubMed  CAS  Google Scholar 

  116. White PF, Way WL, Trevor AJ. Ketamine: its pharmacology and therapeutic uses. Anesthesiology 1982; 56: 119–36

    PubMed  CAS  Google Scholar 

  117. Marx CM, Stein J, Tyler MK, et al. Ketamine-midazolam versus meperidine-midazolam for painful procedures in pediatric oncology patients. J Clin Oncol 1997; 15: 94–102

    PubMed  CAS  Google Scholar 

  118. Parker RI, Mahan RA, Giugliano D, et al. Efficacy and safety of intravenous midazolam and ketamine as sedation for therapeutic and diagnostic procedures in children. Pediatrics 1997; 99:427–31

    PubMed  CAS  Google Scholar 

  119. McDowall RH, Scher CS, Barst SM. Total intravenous anesthesia for children undergoing brief diagnostic or therapeutic procedures. J Clin Anesth 1995; 7: 273–80

    PubMed  CAS  Google Scholar 

  120. Dachs RJ, Innes GM. Intravenous ketamine sedation of pediatric patients in the emergency department. Ann Emerg Med 1997; 29: 146–50

    PubMed  CAS  Google Scholar 

  121. Green SM, Nakamura R, Johnson NE. Ketamine sedation for pediatric procedures: part 1: a prospective series. Ann Emerg Med 1990; 19: 1024–32

    PubMed  CAS  Google Scholar 

  122. Green SM, Kuppermann N, Rothrock SG. Predictors of adverse events with intramuscular ketamine sedation in children. Ann Emerg Med 2000; 35: 35–42

    PubMed  CAS  Google Scholar 

  123. Green SM, Hummel CB, Wittlake WA, et al. What is the optimal dose of intramuscular ketamine for pediatric sedation? Acad Emerg Med 1999; 6: 21–6

    PubMed  CAS  Google Scholar 

  124. Epstein FB. Ketamine dissociative sedation in pediatric emergency medical practice. Am J Emerg Med 1993; 11: 180–2

    PubMed  CAS  Google Scholar 

  125. Petrack EM, Marx CM, Wright MS. Intramuscular ketamine is superior to meperidine, promethazine, and chlorpromazine for pediatric emergency department sedation. Arch Pediatr Adolesc Med 1996; 150: 676–81

    PubMed  CAS  Google Scholar 

  126. Sherwin TS, Green SM, Khan A, et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med 2000; 35: 229–38

    PubMed  CAS  Google Scholar 

  127. Wathen JE, Roback MG, Mckenzie T, et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency department trial. Ann Emerg Med 2000; 36: 579–88

    PubMed  CAS  Google Scholar 

  128. Kennedy RM, McAllister JD. Midazolam with ketamine: who benefits? Ann Emerg Med 2000; 35: 297–9

    PubMed  CAS  Google Scholar 

  129. Carson IW, Moore J, Balmer JP, et al. Laryngeal competence with ketamine and other drugs. Anesthesiology 1973; 38: 128–33

    PubMed  CAS  Google Scholar 

  130. Mitchell RK, Koury SI, Stone CK. Respiratory arrest after intramuscular ketamine in a 2-year-old child. Am J Emerg Med 1996; 14: 580–1

    PubMed  CAS  Google Scholar 

  131. Taylor PA, Towey RM. Depression of laryngeal reflexes during ketamine anaesthesia. BMJ 1971; II: 688–9

    Google Scholar 

  132. Havel CJ, Strait RT, Hennes H. A clinical trial of propofol vs midazolam for procedural sedation in a pediatric emergency department. Acad Emerg Med 1999; 6: 989–97

    PubMed  Google Scholar 

  133. Seikel K, Smith K. The safety and efficacy of propofol for procedures and imaging in the pediatric emergency department [abstract]. Pediatrics 1999; 104 Suppl.: 691

    Google Scholar 

  134. Green SM. Propofol for emergency department procedural sedation: not yet ready for prime time. Acad Emerg Med 1999; 6: 975–8

    PubMed  CAS  Google Scholar 

  135. Kohrs R, Durieux M. Ketamine: teaching an old dog new tricks. Anesth Analg 1998; 87: 1186–93

    PubMed  CAS  Google Scholar 

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Acknowledgements

The authors are grateful for the time and efforts of Cindy Kane, Kristine Kulage and Amy Hall in the preparation of this manuscript.

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Kennedy, R.M., Luhmann, J.D. Pharmacological Management of Pain and Anxiety During Emergency Procedures in Children. Paediatr Drugs 3, 337–354 (2001). https://doi.org/10.2165/00128072-200103050-00003

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