This excellent post was written by Stephanie Davis, a senior pediatric resident from Cincinnati Children’s Hospital Medical Center.
To sedate or not to sedate… That is the question you may want to ask Child Life.
For me, sedation encompasses oral or intranasal midazolam and IV ketamine. There are a variety of other options out there including dexmedetomidine and propofol. Because the majority of what we use here is midazolam and ketamine, that’s where I’ll focus my efforts. Choosing sedation is tricky, and there is overall a lack of research on which agent is best at which age, which procedures, and at what dose. There is good data, however, showing both midazolam and ketamine are safe in kids. So you have options! I enlisted the help of a few different EM Attendings and Child Life staff to offer some advice.
Too often as a resident I’ve had that 4-year-old girl with a facial laceration that I thought was going to do well with local anesthesia, and it turns out both the patient and I could have benefited from a little midazolam on board. Because I’m the type of physician that likes a minimalist approach, I often try to perform procedures with the least amount of sedation required. I’ve had success with this approach in some children, but not in others. I wanted to spend some time this month figuring out what went wrong and how to more appropriately choose sedation for my patients.
First off, there are many different types of 4-year-olds with facial lacerations. Before the provider even walks in the room, there are inherent qualities to the situation that are going to make it a more or less difficult procedure – patient developmental stage, anxiety, pain, child-parent relationship, previous experiences with healthcare, etc. CALL CHILD LIFE! They will help you navigate through this information. Not only are they experts in child development and coping, but they have the time and the techniques to really tease out what is the best option for the child. It is totally within their scope of practice to make recommendations regarding sedation. So call Child Life early, and ask for their opinion about sedation if it is not readily offered.
Here are some general tips from our Child Life friends in the ED:
Assess not only the child, but also the parent-child interaction
This is important. I do this each time I enter a room, but I don’t always think about how it relates to procedural anxiety. An anxious or upset parent makes for a very anxious and very upset child, irrespective of a pain. Even if the laceration is on the face, and you see beautiful blanching from the LET you placed on there 45 minutes ago so you know it is pain-free, if the parents are not on board your chances of cooperation from the child is minimal without taking some additional steps. If you encounter a situation like this, it is probably best the parent not be involved in the procedure. Instead, Child Life can take the responsibility of distracting and comforting the child.
Offer to let parents leave the room during the procedure
Along the same lines as above, some parents just make the situation worse (to no fault of their own). Let them know it is okay to leave the room. Many will want to step out but feel they should stay to be with the child. Child Life can take on this role instead, allowing parents to be more comfortable leaving the room.
Involve Child Life before you’ve made a decision regarding sedation
Go see the patient. Take mental notes about the patient’s developmental stage, affect, distractibility, and the parent-child interaction. Discuss options for sedation and feel out the parents’ thoughts about how their child will do with the procedure and what their preferences are. Then leave it open ended, step out of the room, and call Child Life to come assess. Child Life can spend much more time with the family exploring what works well for the patient before the procedure starts. Some of this happens by talking to the family, but a lot of the information they gather is from observation, how the child reacts during the prep phase (playing with the tools you will use), and from other procedures the child has (i.e. IV placement). Ask their opinion about sedation and make a multidisciplinary decision about what will work best.
- At 2 years, children develop recall. Prior to 2 years, however, most children will not remember (and therefore not be traumatized by) a procedure. In these cases, you can consider just using local anesthetic.
- At 3 years, most children can engage in pre-procedure prep (playing with and learning about the tools you will use). This looks different depending on how old the child is.
- Think about what you need the sedation for. Local anesthetic is usually sufficient anesthesia for laceration repairs. Depending on the child, you may consider midazolam for anxiolysis. More painful procedures such as extensive I&D’s or reductions usually require IV ketamine for its anesthetic and amnestic properties (and immobilization).
Setting up for the procedure is a crucial step and can make or break the experience
This is another reason to involve Child Life. They have a ton of experience in manipulating the room to make the procedure more comfortable for everyone (including the provider!).
A few tips I’ve learned this month:
- Burrito Roll: Similar to swaddling a baby, roll the child in a sheet tucking the edges in snuggly. This helps your holder and increases safety of the procedure.
- For anything on the forehead, position yourself at the head of the bed. This way the patient does not see your tools and can focus his/her attention forward to engage with Child Life.
- Think of your holder. Adjust the bed and find positions that are comfortable for BOTH of you.
As the provider doing the procedure, keep quiet!
This was new to me. As the person doing the procedure, any attention you draw to yourself will remind the child they are having a painful procedure done. It is best to keep quiet and work quickly. Let Child Life or the caregiver distract the child. Although we all want to say, “You’re doing a great job!,” try to refrain.
If you’d like to read more about procedural sedation
Pacheco GS, Feravorni A. Pediatric procedural sedation and analgesia. Emerg Med Clin North Am. 2013 Aug;31(3):831-52. PMID: 23915606
Hartling L, Milne A, Fois M, Land ES, Sinclair D, Klassen TP, Evered L. What Works and What’s Safe in Pediatric Emergency Procedural Sedation: An Overview of Reviews. Acad Emerg Med. 2016 May;23(5):519-30. PMID: 26858095
