Treating Children’s Pain in the Emergency Room

Preventing, detecting and treating pain is today an ethical imperative that strongly involves the paediatric world1,2. In hospital the measurement of pain should have the same relevance as that of the essential vital parameters and be constantly monitored at all the stages of hospital treatment. Despite this, the customary procedure for medications for pain control is still insufficient.
Paracetamol and NSAIDs have always been used at home in the most common situations (even if often at inappropriate dosage) but it is essential, especially in hospital, to become more confident with more effective drugs3. Pain must be treated constantly within Accident and Emergency departments and there are countless opportunities for appropriate analgesia4.5. Of the procedural analgo-sedation (in other words, how to modify the state of consciousness pharmacologically and the perception of pain in the child who is subjected to painful manoeuvres) in the emergency department has recently taken a national consensus document promoted by the Italian Society of Emergency Medicine and Urgent Care and by the Meyer University Hospital in Florence.6 The objectives of the document include identifying the drugs that can be used for analgo-sedation by doctors who are not anaesthetists, when local anaesthesia (the first essential measure to be taken) is not sufficient to guarantee well-being during a painful procedure. We provide some indications below:
Midazolam: the first choice in sedation for short-term procedures, alone or in association with local anaesthetics for pain control. It can be administered nasally (with MAD nasal atomiser), orally (galenic syrup) or intravenously, and has a good safety profile with a reduced incidence of adverse effects (rare paradoxical reaction, vomiting in 5% of cases if associated with opioids). The combined use of midazolam with ketamine, opioids or nitrous oxide (N2O2) requires greater attention because it can cause a state of deep sedation with desaturation (≤0.5%) that requires expertise in airway management.
Fentanyl: an opioid with shorter duration of action than morphine and indicated for short-term procedures. It provides exclusively analgesic coverage and for sedation should be associated with midazolam or propofol, taking care in this case to monitor the risk of respiratory depression in deep sedation even after the end of the procedure. Administered individually and nasally, it is safe, effective and does not lead to respiratory depression. Intravenous administration should be slow to avoid the onset of chest stiffness.
Nitrous oxide: 50% premixed with O2 is indicated for mild painful procedures with minimal or moderate sedation. It can be administered with a mask on-demand in co-operative children (>5-6 years) or in continuous flow in very young children. It has an excellent safety profile, does not lead to respiratory depression and only occasionally to dysphoria and vomiting (5% of cases). For moderate painful procedures, it may be associated with fentanyl, but in this case, there is a risk of deep sedation and respiratory depression that can be resolved by stopping the administration of N2O2.
Ketamine: should be used intravenously or intramuscularly in moderate and severe pain procedures when other drugs are inadequate. It has analgesic and sedative properties and causes a dissociative state while maintaining the pharyngeal reflex of airway protection and spontaneous breathing. Vomiting is a common side effect. In the recovery phase the emergence reaction (confusion, hallucinations, delirium) is quite frequent (7-10%), especially in adolescents, a situation that can be treated with midazolam. The need for balloon ventilation occurs in 1-2% of cases and laryngospasm and apnoea may occur, which require expertise in airway management. The use of propofol, an association reserved for specialists, is more delicate.
Propofol: short-acting intravenous anaesthetic. It has hypnotic properties without analgesic effect and requires expertise in airway management in case of respiratory and haemodynamic adverse events. Its safety profile ensures that it is recommended to use it as a third-line drug in agreement with the anaesthesiologist staff.
Dexmedetomidine: it has an alpha-2 agonist activity with sedative and anxiolytic effects but with a moderate analgesic role. Intravenous, intramuscular, nasal or oral administration does not cause respiratory depression maintaining the protective reflex on the respiratory tract. It has a rather prolonged duration of action and is used in non-painful procedures and in sedation for the execution of EEG.

The Table below shows a summary of the main characteristics of the drugs. It is hoped that greater knowledge of their indications and limits can lead to a more appropriate and safe use whenever there is a need.