This page intentionally left blank EMERGENCY SEDATION AND PAIN MANAGEMENT Procedural sedation and analgesia represents one of the great advances in the maturation of emergency medicineas a discrete specialtywithin medicine.Oncetheexclusive domain of the anesthesiologist, sedation and pain management procedures are now a routine part of all emergency department practices. Emergency Sedation and Pain Management is a comprehensive medical text addressing emergency sedation and analgesia with specific emphasis on treatment of the emergency department patient. The easi ly accessible, clinically oriented format allows the reader fast and efficient access to the key points in each chapter. The text presents a clinical approach to the treatment of pain in emergency patients, including pediatric and adult populations. Analgesia, sedation, and anesthetic techniques are presented in an informative, authoritative, and concise format – written and edited by physicians with extensive research as well as clinical emergency medicine expertise. The chapters are richly supplemented with tables, photographs, and step-by-step illustrations. john h. burton, md, has been the Resi dency Program Director in Emergency Medicine and a Professor of Emergency Medicine at Albany Medical College in Albany, NY, since 2006. From 1999 to 2003, Dr. Burton was the Medical Director for Maine Emergency Medical Services and, from 1995 to 2006, he worked in the Department of Emergency Medicine at the Maine Medical Cente r in Portland. He was the founding Research Director in the Department of Emergency Medicine at Maine Medical Center. Dr. Burton’s areas of research interest are procedural sedation and analgesia, emergency medical services, and management of cardiovascular emergencies. He has published extensively in the emergency medicine literature on thes e and related topics. He has received awards and peer recognition throughout his academic career noting a commitment to the specialty of emergency medicine. Dr. Burton completed medical school at the University of North Carolina at Chapel Hill in 1992 and residency training at the University of Pittsburgh Affiliated Residency in Emergency Medicine in 1995. james miner, md, facep, has been the Director of Performance Improvement and the Associate Research Director in the Department of Emergency Medicine at Hennepin County Medical Center since 1999 and is an Associate Professor of Emergency Medicine at the University of Minnesota Medical School. Dr. Miner has performed extensive research in the areas of pain management and procedural sedation in the Emergency Department and has publishe d numerous manuscripts on these topics. He is an associate editor of Academic Emergency Medicine. Dr. Miner completed medical school at Mayo Medical School in 1996 and residency training at the Hennepin County Medical Center in Emergency Medicine in 1999. Emergency Sedation and Pain Management Edited by JOHN H. BURTON Albany Medical College JAMES MINER University of Minnesota School of Medicine CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK First published in print format ISBN-13 978-0-521-87086-3 ISBN-13 978-0-511-37133-2 © John H. Burton and James Miner 2008 Every effort has been made in preparing this book to provide accurate and up-to-date information that is in accord with accepted standards and practice at the time of publication. Nevertheless, the authors, editors, and publisher can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors, and publisher therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. 2007 Information on this title: www.cambridge.org/9780521870863 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written p ermission of Cambrid g e University Press. ISBN-10 0-511-37133-0 ISBN-10 0-521-87086-0 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not g uarantee that any content on such websites is, or will remain, accurate or a pp ro p riate. Published in the United States of America by Cambridge University Press, New York www.cambridge.org hardback eBook (NetLibrary) eBook (NetLibrary) hardback Contents Acknowledgments page ix List of Contributors xi SECTION ONE. OVERVIEW AND PRINCIPLES IN EMERGENCY ANALGESIA AND PROCEDURAL SEDATION 1 1 Emergency Analgesia Principles James Miner and John H. Burton 1 2 Emergency Procedural Sedation Principles John H. Burton and James Miner 5 3 Analgesic and Procedural Sedation Principles Unique to the Pediatric Emergency Department Susan Fuchs 11 4 Pain and Analgesia in the Infant Michelle P. Tomassi 18 5 Provider Bias and Patient Selection for Emergency Department Procedural Sedation and Analgesia Knox H. Todd 25 6 Federal and Hospital Regulatory Oversight in Emergency Department Procedural Sedation and Analgesia Sharon Roy 30 7 Nursing Considerations in Emergency Department Procedural Sedation and Analgesia Tania D. Strout and Dawn B. Kendrick 38 SECTION TWO. ANALGESIA FOR THE EMERGENCY PATIENT 43 8 Pharmacology of Commonly Utilized Analgesic Agents Eustacia Jo Su 43 9 Patient Assessment: Pain Scales and Observation in Clinical Practice Tania D. Strout and Dawn B. Kendrick 55 10 Pathways and Protocols for the Triage Patient with Acute Pain Paula Tanabe 67 v 11 Patients with Acute Pain: Patient Expectations and Desired Outcomes David E. Fosnocht, Robert L. Stephen, and Eric R. Swanson 75 12 Analgesia for the Adult and Pediatric Multitrauma Patient Wayne Triner 79 13 Analgesia for the Emergency Department Isolated Orthopedic Extremity Trauma Patient Michael A. Tur turro 87 14 Analgesia for Selected Emergency Eye and Ear Patients Matthew G. Dunn 91 15 Analgesia for the Emergency Headache Patient James Miner 96 16 Analgesia for the Emergency Chest Pain Patient Carl A. Germann and Andrew D. Perron 103 17 Analgesia for the Emergency Back Pain Patient Donald Jeanmonod 109 18 Analgesia for the Acute Abdomen Patient Martha L. Neighbor 120 19 Analgesia for the Renal Colic Patient Allan B. Wolfson and David H. Newman 127 20 Analgesia for the Biliary Colic Patient Allan B. Wolfson and David H. Newman 131 21 Analgesia for the Chronic Pain Patient James Miner 135 22 Outpatient Analgesia following Acute Musculoskeletal Injury John C. Southall 141 SECTION THREE. PROCEDURAL SEDATION FOR THE EMERGENCY PATIENT 147 23 Patient Assessment and Preprocedure Considerations Baruch Krauss and Steven M. Green 147 24 Monitoring for Procedural Sedation Baruch Krauss 152 vi Contents 25 Pharmacology of Commonly Utilized Sedative Agents Eustacia Jo Su 159 26 Procedural Sedation for Pediatric Laceration Repair Mark G. Roback 168 27 Procedural Sedation for Pediatric Radiographic Imaging Studies Nathan Mick 173 28 Procedural Sedation for Brief Pediatric Procedures: Foreign Body Removal, Lumbar Puncture, Bone Marrow Aspiration, Central Venous Catheter Placement Michael Ciccarelli and John H. Burton 179 29 Procedural Sedation for Adult and Pediatric Orthopedic Fracture and Joint Reduction James Miner and John H. Burton 185 30 Procedural Sedation for Electrical Cardioversion Christopher J. Freeman 190 31 Procedural Sedation for Brief Surgical Procedures: Abscess Incision and Debridement, Tube Thoracostomy, Nasogastric Tube Placement Carl Chudnofsky 195 SECTION FOUR. TOPICAL, LOCAL, AND REGIONAL ANESTHESIA APPROACH TO THE EMERGENCY PATIENT 205 32 Selected Topical, Local, and Regional Anesthesia Techniques Douglas C. Dillon and Michael Gibbs 205 33 Topical Anesthesia Considerations for Pediatric Peripheral Intravenous Catheter Placement William T. Zempsky 224 34 Regional Anesthesia for Adult and Pediatric Orthopedic Fracture and Joint Reduction Douglas C. Dillon and Michael Gibbs 230 35 Regional Anesthesia for Dental Pain Kip Benko 237 36 Local Anesthesia for Laceration Repair Joel M. Bartfield 250 Contents vii SECTION FIVE. SPECIAL CONSIDERATIONS FOR EMERGENCY PROCEDURAL SEDATION AND ANALGESIA 255 37 Sedation and Analgesia for the Prehospital Emergency Medical Services Patient Michael Dailey and David French 255 38 Induction Agents for Rapid Sequence Intubation of the Emergency Department Patient Joseph Clinton and Arleigh Trainor 260 39 Sedation and Analgesia for the Critical Care Patient Richard Riker and Gilles L. Fraser 268 Index 277 viii Contents [...]... Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures PEDS 19 92;89 :11 10 11 15 3 Clinical policy for procedural sedation and analgesia in the emergency department American college of emergency physicians Ann Emerg Med 19 98; 663–677 4 Green SM, Krauss B Procedural sedation terminology: Moving beyond ‘‘conscious sedation. ’’ Ann Emerg... Cooper-Patrick L, et al Race, gender, and partnership in the patient–physician relationship JAMA 19 99;282(6):583–589 10 Merskey H The taxonomy of pain Med Clin North Am 2007; 91( 1) :13 –20 11 Thomas SH, et al Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: A prospective, randomized trial J Am Coll Surg 2003 ;19 6 (1) :18 – 31 12 Bijur PE, Kenny MK, Gallagher... North 19 00 East Rm AC 218 Salt Lake City, UT 8 413 2 Tim Sweeney Department of Emergency Medicine Maine Medical Center Portland, ME 0 410 2 Email: sweent@mmc.org Paula Tanabe Department of Emergency Medicine and the Institute for Healthcare Studies Northwestern University 259 E Erie, Suite 10 0 Chicago IL 60 611 Email: Ptanabe2@nmff.org Knox H Todd Professor of Emergency Medicine Director, Pain and Emergency. .. racial and ethnic disparities in pain Pain Med 2003;4 (3):277–294 7 Miner J, et al Patient and physician perceptions as risk factors for oligoanalgesia: A prospective observational study of the relief of pain in the emergency department Acad Emerg Med 2006 ;13 (2) :14 0 14 6 8 Bartfield JM, et al Physician and patient factors influencing the treatment of low back pain Pain 19 97;73(2):209– 211 9 Cooper-Patrick... K The utility of bispectral index in procedural sedation with propofol in the emergency department Acad Emerg Med 2005 ;12 : 19 0 19 6 12 Overview and Principles in Emergency Analgesia and Procedural Sedation nondisplaced fracture, anxiolysis to decrease apprehension of venipuncture, sedation for a painless procedure such as a CT scan, and sedation for a painful procedure such as a displaced fracture reduction... 55 415 Email: Miner 015 @umn.edu Martha L Neighbor 1 Hawks Hill Court Lafayette, CA 9454 9 -1 900 Email: mneighbor@sfghed.ucsf.edu David H Newman Director of Clinical Research Assistant Professor of Clinical Medicine Department of Emergency Medicine St Luke’s/Roosevelt Hospital Center 11 11 Amsterdam Avenue New York, NY 10 025 Email: dnewman@chpnet.org List of Contributors Andrew D Perron Department of Emergency. .. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department Ann Emerg Med 2003;42:636–646 6 Joint Commission on Accreditation of Healthcare Organization Standards for moderate and deep sedation and anesthesia hospital accreditation standards Oakbrook Terrace, Illinois, 2002; Tx:2–Tx.2.4 1, pp 10 8 11 1 7 Miner JR, Biros MH, Seigel... about pain and pain control in emergency medicine Emerg Med Clin North Am 2005;23(2):297–306 4 Jones JS, Johnson K, McNinch M Age as a risk factor for inadequate emergency department analgesia Am J Emerg Med 19 96 ;14 (2) :15 7 16 0 5 Friedland LR, Kulick RM Emergency department analgesic use in pediatric trauma victims with fractures Ann Emerg Med 19 94;23(2):203–207 6 Green CR, et al The unequal burden of pain: ... Maine Medical Center Department of Emergency Medicine Research Nurse 3 21 Brackett Street Portland, ME 0 410 2 Email: strout@mmc.org xiii Eustacia Jo Su Chief, Pediatric Emergency Medicine Section Associate Professor, Emergency Medicine and Pediatrics Oregon Health Sciences University 318 1 SW Sam Jackson Park Road CDW-EM Portland, OR 972 01 Email: sue@ohsu.edu Eric R Swanson Division of Emergency Medicine... encounters, particularly practices that routinely confer levels of deep sedation, should be vigilant in their training and preparation for adverse hemodynamic and respiratory events BIBLIOGRAPHY 1 American Society of Anesthesiologists, Task Force on Sedation and Analgesia by Non-Anesthesiologists Practice guidelines for sedation and analgesia by non-anesthesiologists Anesthesiology 2002;96 :10 04 10 17 2 American . print format ISBN -1 3 97 8-0 -5 2 1- 8 708 6-3 ISBN -1 3 97 8-0 - 51 1-3 713 3-2 © John H. Burton and James Miner 2008 Every effort has been made in preparing this book to provide accurate and up-to-date information. University Press. ISBN -1 0 0-5 1 1-3 713 3-0 ISBN -1 0 0-5 2 1- 8 708 6-0 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites. anesthesiologist, sedation and pain management procedures are now a routine part of all emergency department practices. Emergency Sedation and Pain Management is a comprehensive medical text addressing emergency