SCOPE OF THE PROBLEM

Procedural sedation and analgesia (PSA) in the emergency department (ED) is a common component of the modern practice of emergency medicine. The concepts inherent to PSA, however, are not new to emergency care for the sick and wounded.

Medical accounts from authors as early as Hippocrates have included descriptions of painful procedures, such as orthopedic dislocation and fracture reduction, in their accounts of the stabilization of patients with acute medical and traumatic conditions. Along with these descriptions, physicians have often described the use of certain techniques or adjuncts to assuage the pain associated with therapeutic procedures.

Historical depictions of procedure patients have frequently included images of caregivers providing alcohol or inhalational agents to alleviate procedure-related pain and suffering. These concepts have become inherent to our collective view of the role of medical caregivers as both prescribing treatment as well as relief of pain and suffering throughout history.

The rationale for administration of analgesic and/or sedative agents has generally relied upon the reduction of pain and suffering. Modern medical practice recognizes the importance of PSA as being equally important for the provision of a number of additional elements including relaxation of affected muscle groups and tissues adjacent to injured structures, reduction of patient anxiety, and as a means to improve the broad experience of the procedure encounter not only for the patient but also for patient family members and health-care providers alike.

SCOPE OF THE PROBLEM

Pain is the presenting complaint for up to 70% of visits to the emergency department (ED). There are a myriad of strategies to treat and diagnose pain. The effective strategies are those with adequate and timely pain relief without adverse effects.

In 1992, the World Health Organization developed a clinical guideline for the treatment of acute pain. This guideline includes basic instructions to select an appropriate pain medication for the patient's pain intensity, individualize the dose by titration of opioids, and concomitantly provides adjuvant analgesic drugs as co-analgesics or to counteract side effects.

It has been shown that patients frequently receive inadequate analgesia in the ED. Oligoanalgesia, the inadequate treatment of pain, frequently occurs in the ED, especially in those patients at the extremes of age and members of minority and ethnic groups.

Treatment of pain is essentially a simple process, and a wide variety of agents and techniques are available that are generally effective. Morphine has been recognized as a basic treatment for pain throughout the modern era of allopathic medicine. It is effective, easy to obtain, and has never been expensive. However, morphine has severe side effects when overused, specifically in the acute setting with respiratory depression, hypotension, and a decreased ability to report worsening symptoms. Issues with the chronic use of morphine, as with all opiates, include suppression of the endorphin system with associated vegetative changes and physiologic dependence.

SCOPE OF THE PROBLEM

The pediatric population accounts for a large percentage of emergency department (ED) visits annually. Many of these patients will require brief, painful procedures either in the ED or in another setting such as the intensive care unit. These procedures also occur frequently in the outpatient clinic or inpatient setting for children with chronic illnesses. To affect an optimal procedural experience for these patients, a pediatric procedure unit or clinical response team of well-trained caregivers has been a recent trend.

Typical procedures for these patients include lumbar puncture, bone marrow aspiration, and central venous catheter placement. These procedures, and other brief diagnostic and therapeutic procedures in this population, are similar to the adult population in the intervention and technique required. They are distinct from their adult counterparts, however, in that the pediatric patient will often require sedation and anxiolysis owing to the child's fear, in addition to a need to create an experience that is positive and supportive instead of a recurrent, negative association with medical care. Younger patients will also often require a brief period of sedation to optimize positioning or minimize movement.

It has been previously documented that there is considerable underuse of analgesia and sedation in children requiring brief, painful medical interventions. The goal of procedural sedation in this setting is to provide sedative, analgesic, and/or dissociative agents to alter recognition of pain and level of consciousness, at the same time maintaining airway reflexes in order to provide symptomatic relief of pain and anxiety.