BRIEF REPORTS

Procedural Pain Management Patterns inAcademic Pediatric Emergency DepartmentsRishi Bhargava, MD, Kelly D. Young, MD, MS

AbstractObjectives: To describe the current state of the art for pain and sedation management for five commonpediatric emergency department (ED) procedure scenarios.

Methods: Fellowship directors of U.S. EDs with a pediatric emergency medicine fellowship training pro-gram were surveyed by mail and asked to choose the one most commonly used pain or sedation manage-ment option for five clinical scenarios: facial laceration repair, cranial computed tomography in a toddler,closed fracture reduction, neonatal lumbar puncture, and intravenous catheter insertion. Results wereanalyzed by using descriptive statistics, and the differences between high and low volume departmentswere compared by using a chi-square test.

Results: Thirty-eight of 51 fellowship programs responded (75%). The majority of respondents werefellowship directors (76%). Topical anesthetics were most commonly reported as used for a simple faciallaceration (84%), whereas ketamine sedation was most popular for fracture reduction (86%). Painmanagement for the other scenarios was more variable. More than half of the respondents (53%) wouldnot sedate at all for cranial computed tomography, and only 38% reported use of pharmacologic painmanagement for intravenous catheter insertion. The majority (74%) reported use of anesthetic (topicalor injected local) for neonatal lumbar puncture. High volume departments were more likely to use painmanagement for intravenous catheter insertions.

Conclusions: Pain and sedation management methods for pediatric procedures continue to evolve. Despitegains, there is still room for improvement, particularly regarding intravenous catheter insertions.

ACADEMIC EMERGENCY MEDICINE 2007; 14:479–482 ª 2007 by the Society for Academic EmergencyMedicine

Keywords: pain, pediatric, emergency department, procedure, sedation, analgesia

Pain is a common concern for emergency depart-ment (ED) patients, and inadequate pain man-agement has been increasingly recognized as

From the Division of Pediatric Emergency Medicine, Loma

Linda University Medical Center (RB), Loma Linda, CA; Depart-

ment of Pediatrics, David Geffen Medical School at University

of California, Los Angeles (KDY), Los Angeles, CA; and Depart-

ment of Emergency Medicine, Harbor-UCLA Medical Center

(KDY), Torrance, CA.

Received July 26, 2006; revision received November 16, 2006;

accepted December 5, 2006.

Dr. Young is supported by the K23 RR16180 Mentored Patient-

Oriented Career Research Award from the National Institutes

of Health, National Center for Research Resources. This project

was supported by the M01 RR00425 National Center for Research

Resources grant (to the Harbor-UCLA General Clinical Research

Center). Dr. Young has served on a 1-day Advisory Board for

Corgentech, Inc., a biopharmaceutical company developing pain

management products.

Contact for correspondence and reprints: Kelly D. Young, MD,

MS; e-mail: kyoung@emedharbor.edu.

ª 2007 by the Society for Academic Emergency Medicine

doi: 10.1197/j.aem.2006.12.006

problematic, particularly for pediatric emergency de-partment (ED) patients.1 Minor procedures, such as ven-ipuncture and laceration repair, are common sources ofpain in pediatric ED patients, and inadequate treatmentmay have long-term effects.2

In response, there has been an increasing emphasison pain management, with recent Joint Commission onAccreditation of Healthcare Organization standards andeven a declaration by Congress supporting improvedpain assessment, treatment, and research.2 An explosionin pediatric pain management research has produced abody of literature and several guidelines that addresspain assessment, management, and sedation and analge-sia regimens for children seen in the ED.2–5

We surveyed U.S. pediatric emergency medicine (EM)fellowship training programs as to their physicians’ pre-ferred methods for sedation and analgesia for a variety ofcommon ED procedure scenarios. We chose EDs withpediatric EM fellowship programs because we believedthat they would be at the forefront regarding outpatientpediatric sedation and analgesia and would thereforerepresent a current state of the art. This assumption issupported by a previous study comparing children’s

ISSN 1069-6563

PII ISSN 1069-6563583 479

480 Bhargava and Young � PEDIATRIC ED PAIN MANAGEMENT PATTERNS

and general hospitals, which found that 99% of children’shospitals provided sedation for fracture reduction, com-pared with 58% of general hospitals.6 Many pediatric EMfellowship programs are located in children’s hospitals.

METHODS

Study Design and PopulationFellowship directors of U.S. EDs with a pediatric EM fel-lowship training program were surveyed by mail regard-ing pain management. This study was reviewed by theinstitutional review board of the Los Angeles BiomedicalResearch Institute at Harbor-UCLA Medical Center andwas approved as not requiring a consent document. Re-turn of the survey was considered implied consent forparticipation. The surveys were anonymous and did notcontain any questions or marks that allowed investiga-tors to identify the responding program.

Survey Content and AdministrationFive common pediatric ED clinical scenarios were studied:suture of a small facial laceration in a 3-year-old, cranialcomputed tomography (CT) imaging in a stable 2-year-old, fracture reduction in an 8-year-old, lumbar puncturein a 3-week-old, and intravenous catheter placement ina 5-year-old. Clinical scenarios were kept brief to avoidleading respondents. A comprehensive list of choices forpain management or sedation was given, as well as ablank, write-in line. Survey drafts were reviewed byseveral pediatric emergency physicians at our institution,to ensure that the list would include a sufficiently broadrange of choices. The choice ‘‘parental support’’ was listedto capture instances in which no pharmacologic methodswould be used. Nonpharmacologic methods, such as dis-traction, music, and imagery, were not included, althoughfor some scenarios, ‘‘child life’’ was a choice.

Respondents were asked to select the single option thatphysicians as a whole in their ED are most likely to usefor each clinical scenario. We also asked respondentsto estimate their total annual pediatric ED volume andto identify their role at the institution. (The survey maybe viewed as an online Data Supplement at http://www.aemj.org/cgi/content/full/j.aem.2006.12.006/DC1.)

Surveys were sent by mail to the program directors forthe 51 U.S. pediatric EM fellowship programs that werelisted in the April 2005 issue of Pediatric EmergencyCare.7 A cover letter was sent with each survey, statingour purpose and assuring respondents that their re-sponses would be kept anonymous and that no identifierswere on the surveys. A repeat survey was sent out to allprograms again 2 months later, with instructions toreturn the second survey only if the first had not yetbeen returned.

Data AnalysisData were entered into a spreadsheet (Excel 2003; Mi-crosoft Corporation, Redmond, WA) and imported foranalysis by using SAS (version 8; SAS Institute, Inc.,Cary, NC) with DBMS Copy 8.0.0 (Data Flux Corp.,Cary, NC). A high volume ED was arbitrarily defined apriori as one with a total annual volume of 50,000 pediat-ric patients or more. No power calculations to determinethe number of high and low volume programs needed

for meaningful comparisons were performed, however.Although respondents were instructed to choose onlyone option, nine chose two options for at least one ofthe five scenarios. In these cases, the data were codedas a 0.5 vote for each option chosen. Descriptive statisticswere used to present categorical variables as propor-tions. For scenarios in which more than one regimenpredominated, the chi-square test was used to explorewhether differences in regimen choice existed betweenhigh and low volume EDs.

RESULTS

Of the 51 pediatric EM fellowship programs surveyed,38 (75%) responded. Respondents were as follows: 76%,pediatric EM fellowship director; 21%, pediatric ED fac-ulty member; and 3%, pediatric ED director. Fifteen (39%)of the EDs were high volume (50,000 or more annualpediatric ED visits).

Pain management or sedative drugs were reportedused by all respondents for laceration repair with sutures(most commonly, topical anesthetics) and for fracturereduction (most commonly, ketamine). Only 48% (95%CI = 31% to 64%) of respondents reported use of phar-macologic methods of pain management or sedation forcranial CT imaging, 80% (95% CI = 63% to 90%) forneonatal lumbar puncture, and 38% (95% CI = 24% to56%) for intravenous catheter placement. Table 1 givesreported methods for each clinical scenario.

There were no significant differences between highand low volume EDs in use of short-acting barbituratesfor cranial CT imaging (regimen of choice for 40% ofhigh volume EDs compared with 26% of low volumeEDs; difference, 14%; 95% CI for difference = �16% to44%), or in use of any anesthetic for neonatal lumbarpuncture (73% of high volume EDs compared with 70%of low volume EDs; difference, 3%; 95% CI for differ-ence = �26% to 32%). High volume EDs were significantlymore likely to use some pharmacologic pain manage-ment method for intravenous catheter placement thanwere low volume EDs (67% compared with 26%, p =0.013; difference, 41%; 95% CI for difference = 11%to 71%). There was no difference between high and lowvolume EDs in selection of a response that included‘‘child life.’’

DISCUSSION

A few previous studies have documented the most com-mon sedation and analgesia regimens used in pediatriccases. The authors of a 1989 survey of pediatric EM fellow-ship programs noted that a meperidine-promethazine-chlorpromazine cocktail (commonly referred to as a DPTcocktail, an acronym for the drug brand names) was themost common sedation method for suturing and com-mented that some practitioners were experimenting withso-called newer medications, such as fentanyl.8 A 1991survey of EM residency directors concluded that themost common medications used for pediatric sedationwere the following: midazolam, meperidine, and chloralhydrate, with 30% of respondents reporting the use ofketamine.9 A 1992 survey of pediatric residency programdirectors found that the most commonly reported

ACAD EMERG MED � May 2007, Vol. 14, No. 5 � www.aemj.org 481

Table 1Pharmacologic Pain and Sedation Management by Clinical Scenario

Clinical Scenario %Pain or Sedation Management Methods

Reported by Respondents

1. 3-yr-old requiring repair of a linear 3-cm lacerationon the chin with sutures

76 LET or TAC topical anesthetic8 EMLA or LMX4 topical anesthetic8 Injected local anesthetic8 Systemic sedation and analgesia (midazolam, ketamine)

2. Otherwise healthy 2-yr-old requiring a head computedtomography scan after seizure

53 No pharmacologic method (42% parental support,5% with papoose, 11% child life)

32 Short-acting barbiturates (29% pentobarbital,3% methohexital)

8 Chloral hydrate8 Systemic sedation (midazolam, propofol)

3. 8-yr-old requiring reduction of a both-bone fractureof the proximal forearm

86 Ketamine (all intravenous)9 Opiate � midazolam (fentanyl, morphine)5 Propofol

4. 3-wk-old (nontoxic appearing) requiring a lumbarpuncture for fever workup

28 EMLA or LMX4 topical anesthetic25 Injected local anesthetic21 Topical + injected local anesthetic20 No pharmacologic method (parental support � child life)

6 Pacifier with sucrose or glucose solution

5. 5-yr-old requiring intravenous catheter placement 62 No pharmacologic method (parental support � child life)26 EMLA or LMX4 topical anesthetic12 Vapocoolant

Percentages add up to 101% for scenario 2 because of rounding.

LET = lidocaine, epinephrine, and tetracaine; TAC = tetracaine, adrenalin, and cocaine; EMLA = eutectic mixture of local anesthetics (AstraZeneca LP,

Wilmington, DE); LMX4 = 4% liposomal lidocaine (Ferndale Laboratories, Ferndale, MI).

sedatives used for painless diagnostic procedures werechloral hydrate, DPT cocktail, and pentobarbital.10

A 1994 survey of ED directors that included 84 chil-dren’s hospitals and 154 general hospitals looked atspecific pediatric clinical scenarios and found thatmidazolam was the drug of choice for fracture reduction;chloral hydrate, for cranial CT imaging; and midazolam,for repair of a toddler’s small facial laceration.6 Evidencefor the evolution of sedation and analgesia regimens waspresent; meperidine was still being used by general hos-pitals but not by children’s hospitals. Five years later,a survey of academic pediatric EM practitioners foundthat midazolam was still the most popular sedative choicefor pediatric cranial CT imaging.11

This study sought to establish the current state of theart for pediatric ED pharmacologic pain and sedationmanagement for common ED procedures. In contrastwith the studies cited above, we demonstrated an in-crease in reported use of topical anesthetics, ketamine,and short acting barbiturates. A few departments alsoreported use of propofol, pacifiers with sucrose or glu-cose, and vapocoolants.

As a result of faster, newer generation CT scanners, se-dation for a noncontrast cranial CT is often not needed.12

Our findings support this concept, with more than half ofrespondents reporting that no sedative would be usedfor cranial CT scanning in toddlers.

Ketamine procedural sedation appears to be mostcommonly used for closed-fracture reduction, with aminority of respondents reporting sedation with opiatesand benzodiazepines or propofol; the use of local hema-toma blocks and Bier blocks was not reported.

Although the use of anesthesia for neonatal lumbarpunctures is still variable, our study contrasted with arecent similar survey in that 80% of our respondents re-ported using some sort of pharmacologic pain manage-ment method, whereas the other survey found that twothirds of academic pediatric EM practitioners did not.13

The difference may reflect a trend toward increased an-esthetic use and awareness of pain management issuesin the two years between the surveys or may reflect dif-ferences between survey respondents.

Finally, although effective pain management methodsfor venipuncture and intravenous catheter insertionsuch as topical anesthetics exist, our survey shows thatthey are not used by the majority.14

LIMITATIONS

We surveyed a small sample of EDs, limiting ourselvesto those with a pediatric EM fellowship. It is likely thatcommon practices are different in general EDs or in hos-pitals without a pediatric EM fellowship. Canadian andother international pediatric EDs also were not included;these limitations reduce the generalizability of the re-sults. Answers were self-reported by one person fromeach department and may not be representative of an in-stitution’s overall practice. No data were collected on thetotal number of physicians represented by each respon-dent’s answers, nor on whether faculty were full orpart time. Response rate was not 100%, which could re-sult in a self-selection bias, whereby those who chooseto respond tend to use different pain managementmethods than the overall group. Clinical scenarios were

482 Bhargava and Young � PEDIATRIC ED PAIN MANAGEMENT PATTERNS

not validated and may not have been interpreted in thesame way by each respondent. The choices that we pro-vided may have been leading or not broad enough.

CONCLUSIONS

Pain and sedation management for common pediatric EDprocedures has evolved in recent years, with increaseduse of topical anesthetics, short-acting barbiturates,and ketamine sedation and increased use of any anesthe-sia for neonatal lumbar punctures. Pain management forintravenous catheter placement remains inadequate.

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5. Krauss B, Green SM. Sedation and analgesia for pro-cedures in children. N Engl J Med. 2000; 342:938–45.

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