Podcasts about can j anaesth

It is worth refreshing your knowledge on local anaesthetic systemic toxicity.     Check out the papers mentioned. Liem EB, Lin CM, Suleman MI, Doufas AG, Gregg RG, Veauthier JM, Loyd G, Sessler DI. Anesthetic requirement is increased in redheads. Anesthesiology. 2004 Aug;101(2):279-83. doi: 10.1097/00000542-200408000-00006. PMID: 15277908; PMCID: PMC1362956. https://pubmed.ncbi.nlm.nih.gov/15277908/  Gradwohl SC, Aranake A, Abdallah AB, McNair P, Lin N, Fritz BA, Villafranca A, Glick D, Jacobsohn E, Mashour GA, Avidan MS. Intraoperative awareness risk, anesthetic sensitivity, and anesthetic management for patients with natural red hair: a matched cohort study. Can J Anaesth. 2015 Apr;62(4):345-55. doi: 10.1007/s12630-014-0305-8. Epub 2015 Feb 14. PMID: 25681040; PMCID: PMC4661058. https://pubmed.ncbi.nlm.nih.gov/25681040/  Liem EB, Joiner TV, Tsueda K, Sessler DI. Increased sensitivity to thermal pain and reduced subcutaneous lidocaine efficacy in redheads. Anesthesiology. 2005 Mar;102(3):509-14. doi: 10.1097/00000542-200503000-00006. PMID: 15731586; PMCID: PMC1692342. https://pubmed.ncbi.nlm.nih.gov/15731586/  El-Boghdadly K, Pawa A, Chin KJ. Local anesthetic systemic toxicity: current perspectives. Local Reg Anesth. 2018 Aug 8;11:35-44. doi: 10.2147/LRA.S154512. PMID: 30122981; PMCID: PMC6087022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6087022/#b26-lra-11-035  RCH Melbourne Guidelines - https://www.rch.org.au/clinicalguide/guideline_index/Local_anaesthetic_poisoning/    www.rnzcuc.org.nz podcast@rnzcuc.org.nz https://www.facebook.com/rnzcuc https://twitter.com/rnzcuc   Music licensed from www.premiumbeat.com Full Grip by Score Squad   This podcast is intended to assist in ongoing medical education and peer discussion for qualified health professionals.  Please ensure you work within your scope of practice at all times.  For personal medical advice always consult your usual doctor

Dr. Chris Di Capua and Dr. Bryan Glezerson (@BryanGlezerson) join the show to discuss the literature around the risk of aspiration with LMAs compared to ETTs. This is an episode produced from the Depth of Anesthesia Podcast Elective that's available to MGH anesthesia residents. Special thanks to Dr. Saddawi-Konefka for supporting the initiative. Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and consider helping us offset the costs of production by donating through our Patreon at https://bit.ly/3n0sklh. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Keller C, Sparr HJ, Luger TJ, Brimacombe J. Patient outcomes with positive pressure versus spontaneous ventilation in non-paralysed adults with the laryngeal mask. Can J Anaesth. 1998 Jun;45(6):564-7. doi: 10.1007/BF03012709. PMID: 9669012. Bernardini A, Natalini G. Risk of pulmonary aspiration with laryngeal mask airway and tracheal tube: analysis on 65 712 procedures with positive pressure ventilation. Anaesthesia. 2009 Dec;64(12):1289-94. doi: 10.1111/j.1365-2044.2009.06140.x. Epub 2009 Oct 23. PMID: 19860753. Qamarul Hoda M, Samad K, Ullah H. ProSeal versus Classic laryngeal mask airway (LMA) for positive pressure ventilation in adults undergoing elective surgery. Cochrane Database Syst Rev. 2017;7(7):CD009026. Published 2017 Jul 20. doi:10.1002/14651858.CD009026.pub2 Maltby JR, Beriault MT, Watson NC, Fick GH. Gastric distension and ventilation during laparoscopic cholecystectomy: LMA-Classic vs. tracheal intubation. Can J Anaesth. 2000 Jul;47(7):622-6. doi: 10.1007/BF03018993. PMID: 10930200. Kim D, Park S, Kim JM, Choi GS, Kim GS. Second generation laryngeal mask airway during laparoscopic living liver donor hepatectomy: a randomized controlled trial. Nature. 2021 Feb 11;11(1):3532. doi: 10.1038/s41598-021-83173-5. PMID: 33574495; PMCID: PMC7878811. Parikh SS, Parekh SB, Doshi C, Vyas V. ProSeal Laryngeal Mask Airway versus Cuffed Endotracheal Tube for Laparoscopic Surgical Procedures under General Anesthesia: A Random Comparative Study. Anesth Essays Res. 2017;11(4):958-963. doi:10.4103/aer.AER_97_17 Park SK, Ko G, Choi GJ, Ahn EJ, Kang H. Comparison between supraglottic airway devices and endotracheal tubes in patients undergoing laparoscopic surgery: A systematic review and meta-analysis. Medicine (Baltimore). 2016 Aug;95(33):e4598. doi: 10.1097/MD.0000000000004598. PMID: 27537593; PMCID: PMC5370819. White LD, Thang C, Hodsdon A, Melhuish TM, Barron FA, Godsall MG, Vlok R. Comparison of Supraglottic Airway Devices With Endotracheal Intubation in Low-Risk Patients for Cesarean Delivery: Systematic Review and Meta-analysis. Anesth Analg. 2020 Oct;131(4):1092-1101. doi: 10.1213/ANE.0000000000004618. PMID: 32925330. Halaseh BK, Sukkar ZF, Hassan LH, Sia AT, Bushnaq WA, Adarbeh H. The use of ProSeal laryngeal mask airway in caesarean section--experience in 3000 cases. Anaesth Intensive Care. 2010 Nov;38(6):1023-8. doi: 10.1177/0310057X1003800610. PMID: 21226432. Nicholson A, Cook TM, Smith AF, Lewis SR, Reed SS. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. doi: 10.1002/14651858.CD010105.pub2. PMID: 24014230.

In this episode I bid farewell to my passing out residents and discuss some trauma myths like Manual in line stabilization and the use of steroids in acute spinal cord injuries. You all can go through the following articles to learn more - 1. Ellis DY, Harris T, Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann Emerg Med. 2007 Dec;50(6):653-65. doi: 10.1016/j.annemergmed.2007.05.006. Epub 2007 Aug 3. PMID: 17681642. 2.Manoach S, Paladino L. Manual in-line stabilization for acute airway management of suspected cervical spine injury: historical review and current questions. Ann Emerg Med. 2007 Sep;50(3):236-45. doi: 10.1016/j.annemergmed.2007.01.009. Epub 2007 Mar 6. PMID: 17337093. 3. Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8. doi: 10.1007/s12630-009-9089-7. Epub 2009 Apr 24. PMID: 19396507. 4. Kapp JP. Endotracheal intubation in patients with fractures of the cervical spine [technical note]. J Neurosurg. 1975;42:731-732. 5. Hachen HJ. Idealized care of the acutely injured spinal cord in Switzerland. J Trauma. 1977;17:931-936 6. Bohlman HH. Acute fractures and dislocations of the cervical spine. An analysis of three hundred hospitalized patients and review of the literature. J Bone Joint Surg Am. 1979;61:1119-1142. 7. Podolsky S, Baraff LJ, Simon RR, et al. Efficacy of cervical spine immobilization methods. J Trauma. 1983;23:461-465. 8. Hugenholtz H, Cass DE, Dvorak MF, Fewer DH, Fox RJ, Izukawa DM, Lexchin J, Tuli S, Bharatwal N, Short C. High-dose methylprednisolone for acute closed spinal cord injury--only a treatment option. Can J Neurol Sci. 2002 Aug;29(3):227-35. doi: 10.1017/s0317167100001992. PMID: 12195611. 9. Suberviola B, González-Castro A, Llorca J, Ortiz-Melón F, Miñambres E. Early complications of high-dose methylprednisolone in acute spinal cord injury patients. Injury. 2008 Jul;39(7):748-52. doi: 10.1016/j.injury.2007.12.005. Epub 2008 Jun 9. PMID: 18541241. 10. Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS, Eisenberg HM, Flamm E, Leo-Summers L, Maroon J, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990 May 17;322(20):1405-11. doi: 10.1056/NEJM199005173222001. PMID: 2278545. 11. Bracken MB, Collins WF, Freeman DF, Shepard MJ, Wagner FW, Silten RM, Hellenbrand KG, Ransohoff J, Hunt WE, Perot PL Jr, et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA. 1984 Jan 6;251(1):45-52. PMID: 6361287. 12. Evaniew N, Noonan VK, Fallah N, Kwon BK, Rivers CS, Ahn H, Bailey CS, Christie SD, Fourney DR, Hurlbert RJ, Linassi AG, Fehlings MG, Dvorak MF; RHSCIR Network. Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Propensity Score-Matched Cohort Study from a Canadian Multi-Center Spinal Cord Injury Registry. J Neurotrauma. 2015 Nov 1;32(21):1674-83. doi: 10.1089/neu.2015.3963. Epub 2015 Jul 17. PMID: 26065706; PMCID: PMC4638202.

For paramedics, click here for CE credits.  Brought to you by Urgent Admin which is an intuitive one-touch solution that connects in-field clinicians and medical directors in real-time, this episode covers the challenge of the prehospital airway. The But Why team covers unique ways to secure the airway that include  "Ghosting the Airway" and "Romantic Hands."   Hear the But Why EMS Podcast team discuss this situation with:   Dr. Robert Stephens Emergency Medicine Resident at Washington University Click here to check it out today! Thank you for listening! Hawnwan Philip Moy MD  Gina Pellerito EMT-P John Reagan EMT-P Noah Bernhardson MD   References: 1. Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013;20(1):71-78. 2. Sakles JC, Mosier J, Stolz U. In reply. Acad Emerg Med 2013;20(9):966. 3. Limkakeng A, Broder JS, Theiling BJ. Chicken or egg? Risks of misattribution of cause-effect relationships in studies of association. Acad Emerg Med 2013;20(9):965. 4. Kajino K, Iwami T, Kitamura T, et al. Comparison of supraglottic airway versus endotracheal intubation for the pre-hospital treatment of out-of-hospital cardiac arrest. Crit Care 2011;15(5):R236. 5. Clemency BM, Roginski M, Lindstrom HA, et al. Paramedic intubation: patient position might matter. Prehosp Emerg Care 2014;18(2):239-243. 6. Murphy DL, Rea TD, McCoy AM, et al. Inclined position is associated with improved first pass success and laryngoscopic view in prehospital endotracheal intubations. Am J Emerg Med 2019;37(5):937-941. 7. Turner JS, Ellender TJ, Okonkwo ER, et al. Feasibility of upright patient positioning and intubation success rates At two academic EDs. Am J Emerg Med 2017;35(7):986-992. 8. Levitan RM, Kinkle WC, Levin WJ, et al. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Ann Emerg Med 2006;47(6):548-555. 9. Snider DD, Clarke D, Finucane BT. The "BURP" maneuver worsens the glottic view when applied in combination with cricoid pressure. Can J Anaesth 2005;52(1):100-104. 10. Tournadre JP, Chassard D, Berrada KR, et al. Cricoid cartilage pressure decreases lower esophageal sphincter tone. Anesthesiology 1997;86(1):7-9. 11. Chassard D, Tournadre JP, Berrada KR, et al. Cricoid pressure decreases lower oesophageal sphincter tone in anaesthetized pigs. Can J Anaesth 1996;43(4):414-417. 12. Garrard A, Campbell AE, Turley A, et al. The effect of mechanically-induced cricoid force on lower oesophageal sphincter pressure in anaesthetised patients. Anaesthesia 2004;59(5):435-439. 13. Heath KJ, Palmer M, Fletcher SJ. Fracture of the cricoid cartilage after Sellick's manoeuvre. Br J Anaesth 1996;76(6):877-878. 14. Notcutt W. Oesophageal rupture and cricoid pressure. Anaesthesia 1991;46(5):424-425. 15. Savino PB, Reichelderfer S, Mercer MP, et al. Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis. Acad Emerg Med 2017;24(8):1018-1026. 16. Messa MJ, Kupas DF, Dunham DL. Comparison of bougie-assisted intubation with traditional endotracheal intubation in a simulated difficult airway. Prehosp Emerg Care 2011;15(1):30-33. 17. Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA 2018;319(21):2179-2189. 18. Driver B, Dodd K, Klein LR, et al. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med 2017;70(4):473-478 e471. 19. Latimer AJ, Harrington B, Counts CR, et al. Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting. Ann Emerg Med 2021;77(3):296-304. 20. Braude D, Richards M. Rapid Sequence Airway (RSA)--a novel approach to prehospital airway management. Prehosp Emerg Care 2007;11(2):250-252. 21. Braude D, Southard A, Bajema T, et al. Rapid sequence airway using the LMA-Supreme as a primary airway for 9 h in a multi-system trauma patient. Resuscitation 2010;81(9):1217. 22. Moss R, Porter K, Greaves I, et al. Pharmacologically assisted laryngeal mask insertion: a consensus statement. Emerg Med J 2013;30(12):1073-1075.  

Dr. Tony Anderson, an anesthesiologist at the Stanford University School of Medicine, joins us to discuss the evolving literature and evidence around perioperative management of buprenorphine. Special thanks to Dr. Ashwini Joshi for her assistance with researching for the episode.  Thanks for listening! If you enjoy our content, leave a 5-star review on Apple Podcasts and consider helping us offset the costs of production by donating through our Patreon at https://bit.ly/3n0sklh. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast and literature updates. Email us at depthofanesthesia@gmail.com with episode ideas or if you'd like to join our team. Music by Stephen Campbell, MD. — References Anderson TA, Quaye ANA, Ward EN, Wilens TE, Hilliard PE, Brummett CM. To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine. Anesthesiology. 2017 Jun;126(6):1180-1186. doi: 10.1097/ALN.0000000000001633. PMID: 28511196; PMCID: PMC7041233. Goel A, Azargive S, Lamba W, Bordman J, Englesakis M, Srikandarajah S, Ladha K, Di Renna T, Shanthanna H, Duggan S, Peng P, Hanlon J, Clarke H. The perioperative patient on buprenorphine: a systematic review of perioperative management strategies and patient outcomes. Can J Anaesth. 2019 Feb;66(2):201-217. English. doi: 10.1007/s12630-018-1255-3. Epub 2018 Nov 27. PMID: 30484167. Goel A, Azargive S, Weissman JS, Shanthanna H, Hanlon JG, Samman B, Dominicis M, Ladha KS, Lamba W, Duggan S, Di Renna T, Peng P, Wong C, Sinha A, Eipe N, Martell D, Intrater H, MacDougall P, Kwofie K, St-Jean M, Rashiq S, Van Camp K, Flamer D, Satok-Wolman M, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth. 2019 Aug;123(2):e333-e342. doi: 10.1016/j.bja.2019.03.044. Epub 2019 May 29. PMID: 31153631; PMCID: PMC6676043. Hansen LE, Stone GE, Matson CA, Tybor DJ, Pevear ME, Smith EL. Total joint arthroplasty in patients taking methadone or buprenorphine/naloxone preoperatively for prior heroin addiction: a prospective matched cohort study. J Arthroplasty 2016; 31: 1698-701. (29) Höflich AS, Langer M, Jagsch R, Bäwert A, Winklbaur B, Fischer G, Unger A. Peripartum pain management in opioid dependent women. Eur J Pain. 2012 Apr;16(4):574-84. doi: 10.1016/j.ejpain.2011.08.008. PMID: 22396085; PMCID: PMC3290684. Li A, Schmiesing C, Aggarwal AK.Evidence for Continuing Buprenorphine in the Perioperative Period. Clin J Pain. 2020 Oct; 36(10): 764-774.doi: 10.1097/AJP.0000000000000858. PMID: 32520814 Macintyre PE, Russel RA, Usher KA, Gaughwin M, Huxtable CA. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care 2013; 41: 222-30 (27) Meyer M, Paranya G, Keefer Norris A, Howard D. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur J Pain. 2010 Oct;14(9):939-43. doi: 10.1016/j.ejpain.2010.03.002. Epub 2010 May 4. PMID: 20444630. Quaye A, Potter K, Roth S, Acampora G, Mao J, Zhang Y. Perioperative Continuation of Buprenorphine at Low-Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation. Pain Med. 2020 Sep 1;21(9):1955-1960. doi: 10.1093/pm/pnaa020. PMID: 32167541.

In this episode, Dr. Ross Kennedy and Dr. Cas Woinarski join us to discuss the evidence on whether low-flow anesthesia with sevoflurane is safe. We discuss Compound A generation and nephrotoxicity. Thanks for listening! If you enjoy our content, consider helping us offset the costs of production by donating through our Patreon at https://bit.ly/3n0sklh. — Follow us on Instagram @DepthofAnesthesia and on Twitter @DepthAnesthesia for podcast updates and new literature updates. Email us at depthofanesthesia@gmail.com. Music by Stephen Campbell, MD. — References Ebert TJ, Frink EJ Jr, Kharasch ED. Absence of biochemical evidence for renal and hepatic dysfunction after 8 hours of 1.25 minimum alveolar concentration sevoflurane anesthesia in volunteers. Anesthesiology. 1998 Mar;88(3):601-10. doi: 10.1097/00000542-199803000-00008. PMID: 9523801. Ebert TJ, Messana LD, Uhrich TD, Staacke TS. Absence of renal and hepatic toxicity after four hours of 1.25 minimum alveolar anesthetic concentration sevoflurane anesthesia in volunteers. Anesth Analg. 1998 Mar;86(3):662-7. doi: 10.1097/00000539-199803000-00042. PMID: 9495434. Eger EI 2nd. Compound A: does it matter? Can J Anaesth. 2001 May;48(5):427-30. doi: 10.1007/BF03028302. PMID: 11394507. Eger EI 2nd, Gong D, Koblin DD, Bowland T, Ionescu P, Laster MJ, Weiskopf RB. Dose-related biochemical markers of renal injury after sevoflurane versus desflurane anesthesia in volunteers. Anesth Analg. 1997 Nov;85(5):1154-63. doi: 10.1097/00000539-199711000-00036. PMID: 9356118. Eger EI 2nd, Koblin DD, Bowland T, Ionescu P, Laster MJ, Fang Z, Gong D, Sonner J, Weiskopf RB. Nephrotoxicity of sevoflurane versus desflurane anesthesia in volunteers. Anesth Analg. 1997 Jan;84(1):160-8. doi: 10.1097/00000539-199701000-00029. PMID: 8989018. Feldman JM, Hendrickx J, Kennedy RR. Carbon Dioxide Absorption During Inhalation Anesthesia: A Modern Practice. Anesth Analg. 2021 Apr 1;132(4):993-1002. doi: 10.1213/ANE.0000000000005137. PMID: 32947290. Fukuda H, Kawamoto M, Yuge O, Fujii K. A comparison of the effects of prolonged (>10 hour) low-flow sevoflurane, high-flow sevoflurane, and low-flow isoflurane anaesthesia on hepatorenal function in orthopaedic patients. Anaesth Intensive Care. 2004 Apr;32(2):210-8. doi: 10.1177/0310057X0403200208. PMID: 15957718. Keijzer C, Perez RS, de Lange JJ. Compound A and carbon monoxide production from sevoflurane and seven different types of carbon dioxide absorbent in a patient model. Acta Anaesthesiol Scand. 2007 Jan;51(1):31-7. doi: 10.1111/j.1399-6576.2006.01187.x. Epub 2006 Nov 10. PMID: 17096668. Kennedy RR, Hendrickx JF, Feldman JM. There are no dragons: Low-flow anaesthesia with sevoflurane is safe. Anaesth Intensive Care. 2019 May;47(3):223-225. doi: 10.1177/0310057X19843304. Epub 2019 May 24. PMID: 31124374. Kharasch ED, Frink EJ Jr, Artru A, Michalowski P, Rooke GA, Nogami W. Long-duration low-flow sevoflurane and isoflurane effects on postoperative renal and hepatic function. Anesth Analg. 2001 Dec;93(6):1511-20, table of contents. doi: 10.1097/00000539-200112000-00036. PMID: 11726433. Mazze RI, Jamison RL. Low-flow (1 l/min) sevoflurane: is it safe? Anesthesiology. 1997 Jun;86(6):1225-7. doi: 10.1097/00000542-199706000-00001. PMID: 9197289. McGain F, Bishop JR, Elliot-Jones LM, Story DA, Imberger GL. A survey of the choice of general anaesthetic agents in Australia and New Zealand. Anaesth Intensive Care. 2019 May;47(3):235-241. doi: 10.1177/0310057X19836104. Epub 2019 May 15. PMID: 31088129.

Our guest today is Dr. Keith Baker, Vice Chair of Education at Massachusetts General Hospital.  We investigate the claim that emergence from sevoflurane is substantially faster than from isoflurane. We explore rationales and discuss cost.  Connect with us @DepthAnesthesia on Twitter or email us at depthofanesthesia@gmail.com. Thanks for listening! Please rate us on iTunes and share with your colleagues.  Music by Stephen Campbell, MD.  -- References Seitsonen ER, Yli-Hankala AM, Korttila KT. Similar recovery from bispectral index-titrated isoflurane and sevoflurane anesthesia after outpatient gynecological surgery. J Clin Anesth. 2006;18(4):272-279. doi:10.1016/j.jclinane.2005.12.005 Gupta A, Stierer T, Zuckerman R, Sakima N, Parker SD, Fleisher LA. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: a systematic review. Anesth Analg. 2004;98(3):. doi:10.1213/01.ane.0000103187.70627.57 Gauthier A, Girard F, Boudreault D, Ruel M, Todorov A. Sevoflurane provides faster recovery and postoperative neurological assessment than isoflurane in long-duration neurosurgical cases. Anesth Analg. 2002;95(5):. doi:10.1097/00000539-200211000-00052 Ries CR, Azmudéh A, Franciosi LG, Schwarz SK, MacLeod BA. Cost comparison of sevoflurane with isoflurane anesthesia in arthroscopic menisectomy surgery. Can J Anaesth. 1999;46(11):1008-1013. doi:10.1007/BF03013193 Maheshwari K, Ahuja S, Mascha EJ, et al. Effect of Sevoflurane Versus Isoflurane on Emergence Time and Postanesthesia Care Unit Length of Stay: An Alternating Intervention Trial. Anesth Analg. 2020;130(2):360-366. doi:10.1213/ANE.0000000000004093 Yasuda N, Targ AG, Eger EI 2nd. Solubility of I-653, sevoflurane, isoflurane, and halothane in human tissues. Anesth Analg. 1989;69(3):370-373.

The following is a short list of salient points related to the podcast and the corresponding source literature. As always, read the source literature and critically appraise it for yourself. Take none of the following as a substitution for local protocol or procedure. 2018 NAEMSP Spinal Immobilization paper https://naemsp.org/resources/position-statements/spinal-immobilization/ Securing a patient to the stretcher mattress significantly reduces lateral motion: Am J Emerg Med. 2016 Apr;34(4):717-21. doi: 10.1016/j.ajem.2015.12.078. Epub 2015 Dec 30. C-Collar limits visible external motion in the intact spine, but not internal motion in the unstable injured spine: Horodyski M, DiPaola CP, Conrad BP, Rechtine GR 2nd. Cervical collars are insufficient for immobilizing an unstable cervical spine injury. J Emerg Med. 2011 Nov;41(5):513-9. doi: 10.1016/j.jemermed.2011.02.001. Epub 2011 Mar 12. PubMed PMID: 21397431. C-Collar increases ICP: Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996 Nov;27(9):647-9. PubMed PMID: 9039362. C-Collar causes distraction of unstable C-spine: Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010 Aug;69(2):447-50. doi:10.1097/TA.0b013e3181be785a. PubMed PMID: 20093981. Lador R, Ben-Galim P, Hipp JA. Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. J Trauma. 2011 Jan;70(1):247-50; discussion 250-1. doi: 10.1097/TA.0b013e3181fd0ebf. PubMed PMID: 21217496. Spinal immobilization negatively impacts the physical exam: March J et al. Changes In Physical Examination Caused by Use of Spinal Immobilization. Prehosp Emerg Care 2002; 6(4): 421 – 4. PMID: 12385610 Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994 Jan;23(1):48-51. PubMed PMID: 8273958. Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8. PubMed PMID: 8782022. Even Manual In Line Stabilization alone increased difficulty during intubation and increases forces applied to the neck: Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8. doi: 10.1007/s12630-009-9089-7. Epub 2009 Apr 24. PubMed PMID: 19396507. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31. doi: 10.1097/ALN.0b013e318190b556. PubMed PMID: 19104166. Spinal immobilization makes it harder to breath and decreases forced expiratory volume: “...produce a significantly restrictive effect on pulmonary function in the healthy, nonsmoking man.” Chan, D., Goldberg, R., Tascone, A., Harmon, S., & Chan, L. (1994). The effect of spinal immobilization on healthy volunteers. Annals of Emergency Medicine, 23(1), 48–51. https://doi.org/10.1016/S0196-0644(94)70007-9 Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkisson A. Respiratory effects of spinal immobilization in children. Ann Emerg Med. 1991 Sep;20(9):1017-9. PubMed PMID: 1877767. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999 Oct-Dec;3(4):347-52. PubMed PMID: 10534038. Prehospital providers can effectively apply selective immobilization criteria without causing harm: Domeier, R. M., Frederiksen, S. M., & Welch, K. (2005). Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Annals of Emergency Medicine, 46(2), 123–131. https://doi.org/10.1016/j.annemergmed.2005.02.004 Out of 32,000 trauma encounters, a prehospital clearance protocol resulted in ONE patient with an unstable injury that was not immobilized. This patient injured her back one week prior, required fixation, but had no neurological injury: Burton, J.H., Dunn, M.G., Harmon, N.R., Hermanson, T.A., and Bradshaw, J.R. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006; 61: 161–167 Ambulatory patients self extricating with a cervical collar results in less cervical spine motion than with the use of a backboard: Shafer, J. S., & Naunheim, R. S. (2009). Cervical Spine Motion During Extrication: A Pilot Study. Western Journal of Emergency Medicine, 10(2), 74–78. https://doi.org/10.1016/j.jemermed.2012.02.082 Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7. doi:10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15. PubMed PMID: 23079144 Lift and slide technique is superior to log roll: Boissy, P., Shrier, I., Brière, S. et al. Effectiveness of cervical spine stabilization techniques. Clin J Sport Med. 2011; 21: 80–88 Despite there not being any randomized control trials evaluating spinal immobilization, patients transferred to hospitals immobilized have more disability than those transported without immobilization: Hauswald, M., Ong, G., Tandberg, D., and Omar, Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998; 5: 214–219 “Mechanism of injury does not affect the ability of clinical criteria to predict spinal injury” Domeier, R.M., Evans, R.W., Swor, R.A. et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury.Prehosp Emerg Care. 1999; 3: 332–337 Spinal immobilization in penetrating trauma is associated with an increased risk of death: Vanderlan, W.B., Tew, B.E., and McSwain, N.E. Jr. Increased risk of death with cervical spine immobilisation in penetrating cervical trauma. Injury. 2009; 40: 880–88 Stuke, L.E., Pons, P.T., Guy, J.S., Chapleau, W.P., Butler, F.K., and McSwain, N.E.Prehospital spine immobilization for penetrating trauma-review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011; 71: 763–769 “The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.” Haut, E.R., Kalish, B.T., Efron, D.T. et al. Spine immobilization in penetrating trauma: more harm than good?. J Trauma. 2010; 68: 115–121 Vanderlan WB, Tew BE, Seguin CY, Mata MM, Yang JJ, Horst HM, Obeid FN, McSwain NE. Neurologic sequelae of penetrating cervical trauma. Spine (Phila Pa 1976). 2009 Nov 15;34(24):2646-53. doi: 10.1097/BRS.0b013e3181bd9df1. PubMed PMID: 19881402. Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Haut ER. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg. 2018 May;84(5):736-744. doi:10.1097/TA.0000000000001764. PubMed PMID: 29283970. Use of LSB can cause sufficient pressure to create pressure ulcers in a short period of time: Cordell W:H, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 Jul;26(1):31-6. PubMed PMID: 7793717. The natural progression of some C-spine injuries is to get worse, sometimes because we force them into immobilization devices, sometimes because of hypotension, vascular injury, or hypoxia, but surprisingly not because of EMS providers… Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ. The cause of neurologic deterioration after acute cervical spinal cord injury. Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6. PubMed PMID: 11224879. Reports of asymptomatic but clinically important spine injuries are, at best, dubious: McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cervical spine fracture: case report and review of the literature. J Trauma. 1990 May;30(5):623-6. Review. PubMed PMID: 2188001. Bresler MJ, Rich GH. Occult cervical spine fracture in an ambulatory patients. Ann Emerg Med. 1982 Aug;11(8):440-2. PubMed PMID: 7103163.

When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible:   (See Adventures in RSI for more)     Supraglottic Airways: for difficult bag-valve-mask ventilation or a difficult airway (details in audio) LMA Classic Pros: Best studied; sizes for all ages Cons: Cannot intubate through aperture   LMA Supreme Pros: Better ergonomics with updated design; bite bloc; port for decompression Cons: Cannot pass appropriate-sized ETT through tube   King Laryngeal Tube Pros: Little training needed; high success rate; single inflation port Cons: Flexion of tube can impede ventilation or cause leaks; only sized down to 12 kg (not for infants and most toddlers)   Air-Q Pros: Easy to place; can intubate through aperture Cons: Not for neonates less than 4 kg   iGel Pros: Molds more accurately to supraglottis; no need to inflate; good seal pressures Cons: Cannot intubate through (without fiberoscopy)   Summary • If you can bag the patient, you're winning. • If you have difficulty bagging, or anticipate or encounter a difficult airway, then don't forget your friend the supraglottic airway (SGA). • Ego is the enemy of safety: SGAs are simple, fast, and reliable. • Just do it.   References Ahn EJ et al. Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2016;2016:6406391. Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015 Apr;25(4):346-62. Byars DV et al. Comparison of direct laryngoscopy to Pediatric King LT-D in simulated airways. Pediatr Emerg Care. 2012 Aug;28(8):750-2.  Carlson JN, Mayrose J, Wang HE. How much force is required to dislodge an alternate airway? Prehosp Emerg Care. 2010 Jan-Mar;14(1):31-5. Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014 Jul;85(7):885-92. Ehrlich PF et al. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004 Sep;39(9):1376-80. Hernandez MR, Klock PA Jr, Ovassapian A. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Anesth Analg. 2012 Feb;114(2):349-68.  Huang AS, Hajduk J, Jagannathan N. Advances in supraglottic airway devices for the management of difficult airways in children. Expert Rev Med Devices. 2016;13(2):157-69. Jagannathan N, Wong DT. Successful tracheal intubation through an intubating laryngeal airway in pediatric patients with airway hemorrhage. J Emerg Med. 2011 Oct;41(4):369-73.  Jagannathan N et al. Elective use of supraglottic airway devices for primary airway management in children with difficult airways. Br J Anaesth. 2014 Apr;112(4):742-8. Jagannathan N, Ramsey MA, White MC, Sohn L. An update on newer pediatric supraglottic airways with recommendations for clinical use. Paediatr Anaesth. 2015 Apr;25(4):334-45. Karsli C. Managing the challenging pediatric airway: Continuing Professional Development. Can J Anaesth. 2015 Sep;62(9):1000-16. Luce V et al. Supraglottic Airway Devices vs Tracheal Intubation in Children: A Quantitative Meta-Analysis of Respiratory Complications. Paediatr Anaesth 24 (10), 1088-1098. Nicholson A et al. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. Ostermayer DG, Gausche-Hill M. Supraglottic airways: the history and current state of prehospital airway adjuncts. Prehosp Emerg Care. 2014 Jan-Mar;18(1):106-15.  Rosenberg MB, Phero JC, Becker DE. Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways. Anesth Prog. 2014 Fall;61(3):113-8.  Schmölzer GM, Agarwal M, Kamlin CO, Davis PG. Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation. 2013 Jun;84(6):722-30. Sinha R, Chandralekha, Ray BR. Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study. Paediatr Anaesth. 2012 Feb;22(2):156-60. Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia. 2011 Dec;66 Suppl 2:45-56. Timmermann A, Bergner UA, Russo SG. Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways. Curr Opin Anaesthesiol. 2015 Dec;28(6):717-26.   Supraglottic Airway on WikEM   This post and podcast are dedicated to Tim Leeuwenburg, MBBS FRACGP FACRRM DRANZCOG DipANAES and Rich Levitan, MD, FACEP for keeping our minds and our patients' airways -- open.  You make us better doctors.  Thank you. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd

N.B.: This month's show notes are a departure from the usual summary.  Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. "Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds). 2017.  Rather than the customary blog post summary, the full chapter (with links) is provided as a virtual reference. INTRODUCTION Pain is multifactorial: it is comprised of physical, psychological, emotional, cultural, and contextual features.  In children often the predominant feature may not be initially apparent.  Although clinicians may focus on the physical component of pain, much time, energy, and suffering can be saved through a holistic approach.  What is the age and developmental stage of the child?  How is the child reacting to his condition?  What are the circumstances?  What is the family or caregiver dynamic? We rely much on how patients and families interact with us to gauge pain.  Assessing and managing children’s pain can be challenging, because they may not exhibit typically recognized signs and symptoms (Srouji 2010).  Further, children participate in and absorb their family’s culture and specific personality from a very young age (Finley 2009).  Knowing the context of the episode may help.  For example, a very anxious caregiver can easily transmit his or her anxiety to the child, which may either inhibit or amplify presentation of symptoms (Bearden 2012). The guiding principles in pediatric pain assessment and management are: know the child; know the family; and know the physiology.  Children have long suffered from an under-treatment of their pain, due both to our incomplete acknowledgement of their pain and our fear of treatment (Howard 2003).  As the pendulum on pain management swings one way or the other, do not let your pediatric patient get knocked by the wayside.  Take a thoughtful approach: know the signs and symptoms, and aggressively treat and reassess. ASSESSMENT Each stage of development offers a unique framework to the child’s signs and symptoms of pain.  In pre-verbal children, use your observational skills in addition to the parent’s report of behavior.  Verbal children can self-report; younger children require pictorial descriptions, while older children and adolescents may use standard adult scales.  In all ages, ask open-ended questions and allow the child to report and speak for himself whenever possible. Neonates Neonates are a unique group in pain assessment.  The neonate (birth to one month of age) has not yet acquired social expression of pain, and his nascent nervous system is only now learning to process it.  Do not expect typical pain behaviors in neonates.  Facial grimacing is a weak indicator of pain in neonates (Liebelt 2000).  When this behavior is present, look for a furrowed brow, eyes squeezed shut, and a vertically open mouth.  Tachycardia, tachypnea, and a change in behavior can be indicators not only to the presence of pain, but possibly to its etiology as well. Neonatal observational scales have been validated in the intensive care and post-operative settings; ED-specific quantitative scales are lacking.  CRIES is a 10-point scale, using a physiologic basis similar to APGAR: Crying; Requires increased oxygen administration (distress and breath-holding); Increased vital signs; Expression; and Sleeplessness (Krechel 1995).  CRIES (Table 1) was validated for post-operative patients; to adapt its use for the ED, the most conservative approach is to substitute “preoperative baseline” with normal range for age.  Although the numerical values of CRIES have not been validated to date in the ED, the clinician may find the domains included in CRIES to be a useful cognitive construct in assessing neonatal pain. Neonatal pain pathways are particularly plastic; prompt assessment of and increased alertness to neonatal pain may help to mitigate long-lived pain sensitivity and hyperalgesia (Taddio 2002).  In other words, treat the neonate’s pain seriously, as you may save him long-term pain sequelae in the future. Infants and Toddlers This group will begin to exhibit more reproducible, reliable signs and symptoms of pain. For infants of less than one year of age, the Neonatal Infant Pain Scale (NIPS) uses observational and physiologic parameters to detect pain (Table 2).  A score of 0-2 indicates no pain present.  A score of 3-4 indicates mild to moderate pain; non-pharmacologic techniques may be tried first.  A score of 5 or greater indicates severe pain; some pharmacologic intervention is indicated (Lawrence 1993). For children greater than one year who are preverbal, a well performing scale is the FLACC score: Face, Legs, Activity, Cry, Consolability (Table 3). Contextual and caregiver features predominate in this group.  Frequent reassessments are helpful, as the initial trepidation and fright in triage may not accurately reflect the child’s overall pain status. Preschool and School-age children Increasing language development offers the hope of more information to the clinician, but be careful not to ask leading questions.  Do not jump directly to “does this hurt?”.  Preschoolers will say ‘yes’ to anything, in an attempt to please you.  School-age children may passively affirm your “statement”, if only to validate their human need for care or attention.  Start with some ice-breaking banter, lay down the foundations for rapport, and then ask open-ended questions.  Be careful not to allow the caregiver to “instruct” the child to tell you where it hurts, how much, how often, etc.  Rather, engage the parents by asking them what behavior they have noticed.  Eliciting history from both the child and the parent will go a long way in constructing a richer picture of the etiology and severity of the pain, and will help to build rapport and trust. The Baker-Wong FACES Pain Rating scale (Figure 1) was developed with feedback from children and has been validated for use in those 3 years of age and older (Keck 1996, Tomlinson 2010). Adolescents Adolescents vary in their development, maturity, and coping mechanisms.  You may see a mixture of childhood and adult behaviors in the same patient; e.g. he may be initially stoic or evades questioning, then later exhibits pseudo-inconsolability.  Do what you can to see the visit from the adolescent’s perspective, and actively transmit your concern and intention to help – many will respond to a warm, open, non-judgemental, and helpful attitude.  The overly “tough” adolescent is likely secretly fearful, and the “dramatic” adolescent may simply be very anxious.  Take a moment to gauge the background behind the presentation. You may use the typical adult scale of 0 (no pain) to 10 (worst pain), or the Faces Pain Scale–Revised (FPS-R).  The FPS-R uses more neutral and realistic faces and, unlike the Wong Baker scale, does not use smiling or crying faces to anchor the extremes of pain (Tsze 2013). PAIN PHYSIOLOGY Pain includes two major components: generation and perception.  Generation of pain involves the actual propagation of painful stimuli, either through nociceptive pain or neuropathic pain.  Nociceptive pain arises from free nerve endings responding to tissue damage or inflammation. Nociceptive pain follows a specific sequence: transduction (an action potential triggered by chemical mediators in the tissue, such as prostaglandins, histamine, bradykinin, and substance P); transmission (the movement of the action potential signal along the nerve fibers to the spinal cord); perception (the impulse travels up the spinothalamic tract to the thalamus and midbrain, where input is splayed out to the limbic system, somatosensory cortex, and parietal and frontal lobes); and modulation (the midbrain enlists endorphins, enkephalins, dynorphin, and serotonin to mitigate pain) (Pasero 2011).  As clinicians we can target specific “stations” along the pain route to target the signal more effectively. Simple actions such as ice, elevation, local anesthetics, or splinting help in pain transduction.  Various standard oral, intranasal, or IV analgesics may help with pain’s transmission. Non-pharmacologic techniques such as distraction, re-framing, and others can help with pain perception.  The sum of these efforts encourage pain modulation. A phenomenon separate from nociceptive pain is neuropathic pain, the abnormal processing of pain stimuli.  It is a dysregulated, chaotic process that is difficult to manage in any setting.  Separating nociceptive from neuropathic symptoms may help to select specific pain treatments and to clarify treatment goals and expectations. Neonates Neonates are exquisitely sensitive to many analgesics.  Hepatic enzymes are immature and exhibit decreased clearance and prolonged circulating levels of the drug administered.  Once the pain is controlled, less frequent administration of medications, with frequent reassessments, are indicated. The neonate’s vital organs (brain, heart, viscera) make up a larger proportion of his body mass than do muscle and fat.  That is to say, the volume of distribution is unique in a neonate.  Water-soluble drugs (e.g. morphine) reach these highly perfused vital organs quickly; relatively small overdosing will have rapid and exaggerated central nervous system and cardiac effects.  The neonate’s small fat stores and muscle mass limit the volume of distribution of lipophilic medications (e.g. fentanyl, meperidine), also making them more available to the central nervous system, and therefore more potent.  Other factors that predispose neonates to accidental analgesic overdose are their decreased concentrations of albumin and other plasma proteins, causing a higher proportion of unbound drug.  Renal clearance is also decreased in the first few months of life. Clinical note: in the ED, neonates often require analgesia for procedures more than for injury.  Non-pharmacologic techniques predominate (see below).  Make liberal use of local anesthetics such as eutectic mixture of local anesthetics (EMLA; for intact skin, e.g. IV access, lumbar puncture) and lidocaine-epinephrine-tetracaine gel (LET; for superficial open skin and soft tissue application).  Oral sucrose (30%) solutions (administered either with a small-volume syringe or pacifier frequently dipped in solution) are effective for minor procedures (Harrison 2010, Stevens 2013) via the release of dopamine and through distraction by mechanical means.  Neonates with severe pain may be managed with parenteral analgesics, on a monitor, and with caution. Infants and Toddlers With increasing body mass comprised of fat stores in conjunction with an increase in metabolism, this group will require a different approach than the neonate.  For many medications, these children will have a greater weight-normalized clearance than adults (Berde 2002).  They will often require more frequent dosing.  Infants and toddlers have a larger functioning liver mass per kilogram of body weight, with implications for medications cleared by cytochrome p-450. Clinical note: some drugs, such as benzodiazepines, will have both a per-kilogram dosing as well as an age-specific modification.  When giving analgesics or anxiolytics to young children, always consult a reference for proper dosing and frequency. School-age children and Adolescents This group retains some hyper-metabolic features of younger children, but the dose-effect relationship is more linear and transparent.  Physiologic clearance is improved, and from a physical standpoint, these are typically lower-risk children.  From a psychological standpoint, this group may need more non-pharmacologic consideration and support to modulate pain optimally. NON-PHARMACOLOGIC TREATMENT The first line of treatment in all pain management is non-pharmacopeia (Horeczko 2016).  Not only is this the safest of all techniques, but often the most effective.  Some are simple comfort measures such as splinting (fracture or sprain), applying cold (acute soft tissue injury) or heat (non-traumatic, non-specific pain), or other targeted non-pharmacology. Many a pain control regimen is sabotaged without consideration of non-pharmacologic techniques, which may augment, or at times replace, analgesics.  Think of non-pharmacopoeia as your “base coat” or “primer” before applying additional coats of analgesic treatment.  With the right base coat foundation, you have a better chance of painting a patient’s symptoms a more tolerable and long-lasting new color. A tailored approach based on age will allow the practitioner to employ a child’s developmental strengths and avoid the frustration that results in asking the child to do what he is not capable of doing.  A brief review of Piaget’s stages of development will help to meet the child at his developmental stage for best effect (Piaget 1928, Sheppard 1977) during acute painful presentations and minor procedures. Sensorimotor stage (from birth to age 2): Children use the five senses and movement to explore the world.  They are egocentric: they cannot see the world from another’s viewpoint.   At 6 to 9 months, object permanence is established: understanding that objects (or people) exist even without seeing them. Preoperational stage (from ages 2 to 7):  Children learn to use language.  Magical thinking predominates. They do not understand rational or logical thinking. Concrete operational stage (from age 7 to early adolescence): Children can use logic, but in a very straightforward, concrete manner (they do well with simple examples).  By this stage, they move from egocentrism to understanding another point of view.  N.B. Some children (and adults) never completely clear this stage. Formal operational stage (early adolescence to adult): children are capable of abstract thinking, rationalizing, and logical thinking. It is important to assess the child’s general level of development when preparing and guiding him through the minor procedure or distracting him until his pain is controlled.  It is not uncommon for acutely ill or injured to regress temporarily in their behavior (not their development) as a coping mechanism. Neonate and Infant (0-12 months) Involve the parent, and have the parent visible to the child at all times if possible.  Make advances slowly, in a non-threatening manner; limit the number of staff in the room.  Use soothing sensory measures: speak softly, offer a pacifier, and stroke the skin softly.  Swaddle the infant and encourage the parent to comfort him during and after the procedure.  Engage their developing sensorimotor skills to distract them. Toddler to Preschooler (1-5 years) Use the same techniques as for the infant, and add descriptions of what he will see, hear, and feel; you can use a doll or toy to demonstrate the procedure.  Use simple, direct language, and give calm, firm directions, one at a time.  Explain what you are doing just before doing it (do not allow too much time for fear or anxiety to take root).  Offer choices when appropriate; ignore temper tantrums.  Distraction techniques include storytelling, bright and flashy toys, blowing bubbles, pinwheels, or having another staff member play peek-a-boo across the room.  The ubiquitous smart phone with videos or games can be mesmerizing at this age. School age (6-12 years) Explain procedures using simple language and (briefly) the reason (understanding of bodily functions is vague in this age group).  Allow the child to ask questions, and involve him when possible or appropriate.  Distraction techniques may include electronic games, videos, guided imagery, and participation in the minor procedure as appropriate. Adolescent (13 and up) Use the same techniques for the school age child, but can add detail.  Encourage questioning.  Impose as few restrictions as possible – be flexible.  Expect more regression to childish coping mechanisms in this age group.  Distraction techniques include electronic games, video, guided imagery, muscle relaxation-meditation, and music (especially the adolescent’s own music, if available). APPLIED PHARMACOLOGY No amount of knowledge of the above physiology, pharmacology, or developmental theory will help your little patient in pain without a well constructed and enacted plan.  Aggressively search out and treat your pediatric patient’s presence and source of pain.  Frequent reassessments are important to ensure that breakthrough pain treatment is achieved, when re-administration is indicated, or when a change of plan is necessary.  This is the time to involve the parents or caregivers to let them know what the next steps are, and what to expect. Start with the least invasive modality and progress as needed.  After non-pharmacologic treatments such as splinting, ice, elevation, distraction, and guided imagery, have an escalation of care in mind (Figure 2). From a pharmacologic perspective, various options are available.  Your pain management plan will differ depending on whether a painful procedure is performed in the ED (Table 4).  Once pain is addressed, create a plan to keep it managed.  Consider the trajectory of illness and the expected time frame of the painful episode.  Include practicalities such as how well the pain may be controlled as an outpatient.  Poorly controlled pediatric pain is more often managed as an inpatient than the same condition in an adult.  Speak frankly with the parents about what drug is indicated for what type of pain and that treatment goals typically do not include absence of all pain, but function in face of the pain, in anticipation for clinical improvement. A special note on codeine: Tylenol with codeine (“T3”) has never been a very effective pain medication, as up to 10% of patients lack enzymatic activity to metabolize it into morphine, its active form (Crews 2014).  New evidence is emerging on the erratic and unpredictable individual metabolism of codeine.  Some children are ultra-rapid-metabolizers of codeine to morphine, causing a rapid “bolus” of the available drug, with respiratory depression and death in some cases (Ciszkowski 2009, Racoosin 2013).  Author’s advice: take codeine off your formulary. COMMON SCENARIOS Head and neck pain Most common non-traumatic head and neck complaints can be managed non-pharmacologically (e.g. headache: improved hydration, sleep, stress, nutrition) or with PO medications, such as NSAIDs.  The anti-inflammatory nature of ibuprofen (10 mg/kg PO q 4-6 h prn, up to adult dose) for example, will treat the cause as well as the symptoms of ear pain, sore throat, and muscular pain.  Ibuprofen may be more effective than acetaminophen (paracetamol) for odontogenic pain (Bailey 2013).  For most applications, acetaminophen may be as effective; however, the combination of both NSAIDs is not likely to be more effective than either agent individually (Merry 2013). True migraine headache may be treated with all of the above, and rescue therapy may include prochlorperamide (0.15 mg/kg IV, up to 10 mg ) (Brousseau 2004), often given with diphenhydramine (1 mg/kg PO or IV, up to 50 mg) and IV fluids.  Ketoralac (0.5 mg/kg IV, up to 10 mg) may be substituted for ibuprofen (Paniyot 2016).  Other specific therapies may be considered, although evidence for them varies. Chest pain After ruling out important pulmonary (e.g. the under-recognized spontaneous pneumothorax) and cardiac (e.g. pericarditis, myocarditis) etiologies, many chest complaints are amenable to NSAIDs.  There is often a large component of anxiety in the child and/or parents in chest pain; no amount of medication will assuage them without addressing their concerns as well. Abdominal pain Abdominal pain in children is challenging, as it is common, often benign, but may be disastrous if the etiology is missed.  For mild pain, consider acetaminophen as indicated (15 mg/kg/dose q 4-6 h prn, up to 650 mg).  The oral route is preferred, but intravenous acetaminophen is an option for patients unable to tolerate PO, or for those in whom the per rectum (PR) route is contraindicated (e.g. neutropenia) (Babl 2011, Dokko 2014).  For children with moderate to severe abdominal pain in whom a nil per os (NPO) status is ideal, consider rehydration/volume repletion, and small, frequent aliquots of a narcotic agent.  Surgical pain is not “erased” by opioids (Thomas 2003, Poonai 2014); treating pain improves specificity to certain surgical emergencies with retained diagnostic accuracy (Manterola 2007).  If there is inter-departmental concern about prolonged effects, sedation, limitation in the physical exam, or there is a need to “see if the pain will come back”, you may opt to use fentanyl initially for its shorter half-life.  More frequent re-assessments may help the surgical team in its deliberations.  Transition quickly to a longer-acting opioid as soon as possible. Long-bone injuries Fracture pain should be addressed immediately with splinting and analgesia.  Oral, intranasal, and intravenous routes are all acceptable, depending on the severity of the injury and symptoms. Intranasal (IN) medications offer the advantage of a fast onset for moderate-to-severe pain (Graudins 2015), either as monotherapy or as a bridge to parenteral treatment (Table 4).  The ideal volume of IN medication is 0.25 mL/naris, with a maximum of 1 mL/naris.  Common concentrations of fentanyl limit its mg/kg use to the school-aged child; intranasal ketamine may be used for pain (i.e. sub-dissociative dose) up to adult weight. Long-bone injuries are a good opportunity to employ a speedy modality that requires little technical skill in administration: nebulized fentanyl.  Clinically significant improvement in pain scales are achieved with 3 mcg/kg/dose of fentanyl administered via standard nebulizer in children 3 years of age or older (Miner 2007, Furyk 2009).  Nebulized fentanyl is a rapid, non-invasive alternative to the IN route for older children, adolescents, or adults, in whom the volume of IN medication would exceed the recommended per naris volume (Deaton 2015). Consider an aggressive, multi-modal approach to control symptom up front.  For example, for a simple forearm fracture, you may opt to give an oral opioid, perform a hematoma block, and offer inhaled nitrous oxide for reduction, rather than a formal intravenous procedural sedation (Luhmann 2006). Ultrasound-guided peripheral nerve blocks are a good pain control adjunct, after initial treatment, and in communication with referring consultants (Ganesh 2009, Suresh 2014). Skin and Soft tissue Skin and soft tissue injuries or abscesses often require solid non-pharmacopoeia in addition to local anesthetics.  For IV cannulation, consider EMLA if the patient is stable and a minor delay is acceptable. Topical ethyl chloride vapo-coolant offers transient pain relief due to rapid cooling and may be used just prior to an IV start (Farion 2008).  Try this: engage your young child’s imagination to distract him and say, “have you ever held a snow ball? You are in luck – it’s just like that – here, do you feel it?”. Vibratory adjuncts such as the “BUZZY” bee can be placed near the IV cannulation site to provide mechanical and cognitive distraction (Moadad 2016). Needleless lidocaine injectors may facilitate IV placement without obscuring the target vein (Spanos 2008, Lunoe 2015).  The medication is propelled into the dermis by a CO2 cartridge that makes a loud popping sound; try this to alleviate anxiety, just before using it: “your skin looks thirsty – it needs a drink – there you are!”. As with any minor procedure, when you tell the child what you are doing, be sure to do it right away.  Do not delay or build suspense. Lidocaine-epinephrine-tetracaine gel (LET) is used for open or mucosal wounds.  Apply as soon as possible in the visit.  The goal of LET is to pretreat the wound to allow for a painless administration of injectable anesthetic.  A common practice to apply LET two or three times at 15-minute intervals for deeper anesthesia, in an attempt to avoid injection altogether.  Researchers are currently working to offer an evidence base to this anecdotal practice. Pediatric burns should be assessed carefully and treated aggressively.  Submersion of the affected extremity in room-temperature water (if possible) or applying room-temperature saline-soaked gauze will both thwart ongoing thermal damage, soothe the wound, and provide foundational first-aid.  Minor burns can be treated topically and with oral medications.  Major burns require IN, IM, or IV analgesics with morphine.  Treatment may escalate to ketamine (Gandhi 2010), in analgesic or dissociative dosing, depending on the context.  Post-traumatic disorders are common in burns; effective pain management is ever-more important in these cases. SPECIFIC SCENARIOS The child with chronic medical problems Children with acute exacerbations of their chronic pain or episodic painful crises require special attention.  Some examples of children with recurring pain are those suffering from sickle cell disease, juvenile idiopathic arthritis, complex regional pain syndrome, and cancer.  Find out whether these symptoms and circumstances are typical for them, and what regimen has helped in the past.  Previous unpleasant experiences may prime these children with amplified anxiety and perception of pain (Cornelissen 2014).  Target the disease process and do your best to show the patient and his family you understand his condition and needs. An equally challenging scenario is the child with chronic pain.  Treat the entire patient with a multimodal approach.  Limit opioids as possible.  As an opioid-sparing strategy or as rescue therapy, consider sub-dissociative ketamine, especially for conditions such as sickle cell crisis, complex regional pain syndrome, autoimmune disorders, or chronic pain due to sub-acute trauma (Sheehy 2015). Intranasal ketamine may be used for sub-dissociative pain control at 0.5 – 1 mg/kg (Andolfatto 2013, Yeaman 2013).  Intravenous infusions of ketamine at 0.1 – 0.3 mg/kg/h may be initiated in the ED and continued 4 – 8 h/d, up to a maximum of 16 h total in 3 consecutive days (Sheehy 2015).  In vaso-occlusive episodes, dexmedetomidine has been shown to be an effective adjunct for severe pain poorly responsive to opioids and/or ketamine (Sheehy 2015b). The child with cognitive impairment Children with cognitive impairment such as those with various genetic or metabolic syndromes, or primary neurologic conditions such as some with cerebral palsy are a challenge to assess and treat properly.  These children not only cannot explain their symptoms, but they also have atypical expressions of pain.  Pain responses in severely intellectually disabled children include a full-blown smile (which may or may not accompany inappropriate laughter), stiffening, and non-cooperation (Hadden 2002).  Other observed behaviors include the freezing phenomenon, in which the child acutely feels the pain, and he abruptly pauses without moving his face for several seconds.  Look also for episodes of unexplained pallor, diaphoresis, breath-holding, and shrill vocalizations. The FLACC has been revised (r-FLACC) for children with cognitive impairment and appears to be reliable for acute care (Malviya 2006). The most distressing and perplexing presentation is the parent who brings his or her child with cognitive impairment for “fussiness”, “irritability”, or “I think he’s in pain”.  Often, this is after significant investigations have been performed, sometimes repeatedly.  Poorly controlled spasticity is an often under-appreciated cause of unexplained pain; treat not with opioids, but with GABA-receptor agonists, such as baclofen or benzodiazepines. Take special precautions in the administration of opioids or benzodiazepines in children with metabolic disorders (e.g. mitochondrial disease) or various syndromes (e.g. Trisomy 21).  They may have a disproportionate reaction to the medication.  Start with a low dose in these children and reassess frequently, titrating in small aliquots as needed. After careful, meticulous investigation in the ED to rule out occult infection, trauma, electrolyte imbalance, or surgical causes, the child with cognitive impairment who continues to be symptomatic despite ED treatment may be admitted for observation.  However, in some cases, the addition of gabapentin to the typical regimen has been shown to manage unexplained irritability in these children (Hauer 2007) by treating visceral hyperalgesia. Multi-trauma The child with multi-trauma is in need of meticulous critical care.  Frequent assessments of pain analgesic response (typically via the intravenous route) are necessary to gauge the child’s trajectory.  Unexplained tachycardia may be the early signs of shock.  Without controlling the child’s pain, it is difficult to distinguish the extreme tachycardia from pain or from blood loss.  If intubated, control the pain first with a fentanyl drip, then use a sedative in addition as needed to keep him comfortable. The child under palliative care Children undergoing palliative care require a multidisciplinary approach.  This includes engaging the patient’s car team as well as “treating” members of the patient’s family.  Examples include the natural course of devastating chromosomal, neurologic, and other congenital conditions; terminal cancer; and trauma, among others (Michelson 2007).  Family dynamics and family members’ needs are often overlooked; the family as a whole must be considered.  Focus on the productive and beneficial treatments that can be offered.  Treat pain promptly, but speak with the parents about end-of-life goals as early as possible, as any analgesic or sedative may have an untoward effect.  You do not want to be caught in the position of potentially precipitously providing cardiopulmonary resuscitation in a child undergoing palliative care, because of a lack of understanding of how increasingly large doses of pain medications can affect breathing and circulation (AAP 2000). Children with ongoing opioid requirements may present not so much with an exacerbation of their chronic pain, but a complication of its treatment.  Identify, assess and aggressively treat constipation, nausea and vomiting, pruritus, and urinary retention (Friedrichsdorf 2007); treating side-effects of pain management may be just as important for quality of life as treating the pain itself. PEARLS AND PITFALLS IN PEDIATRIC PAIN Allow the child to speak for himself whenever possible.  After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you.  Tell me more.” Engage parents and communicate the plan to them.  Elicit their expectations, and give them of preview of what to expect in the ED. Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible.  Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction. Premature infants present a challenge in pain control.  Their pain is under-recognized, as they often display atypical responses to painful stimuli.  Treatment is equally difficult, as they are particularly sensitive to analgesia-sedation.  This is important, as this group is even more likely to undergo painful procedures due to their higher-risk status. Give detailed advice on how to manage pain at home.  Set expectations.  Let them know you understand and will help them through your good advice that will carry them through this difficult time.  Patients and families often just need a plan.  Map it out clearly. SUMMARY In pediatric acute pain, know the child; know the family; and know the physiology. Use your observational skills enhanced with collateral information to assess and reassess for pain in children. Treat pediatric pain well and often. Failure to address the child’s pain has long-lasting consequences. Non-pharmacologic treatments for all, pharmacologic treatments for many. A multi-modal approach is the most effective. Neonates, infants and toddlers, and school-aged children and adolescents exhibit specific physiology in expression of pain and in response to treatment. Tailor your regimen to your young patient’s physiologic pitfalls and needs. References American Academy of Pediatrics. Committee on Bioethics and Committee on Hospital Care. Palliative care for children. Pediatrics. 2000 Aug;106(2 Pt 1):351-7. Andolfatto G, Willman E, Joo D, Miller P, Wong WB, Koehn M, Dobson R, Angus E, Moadebi S. Intranasal ketamine for analgesia in the emergency department: a prospective observational series. Acad Emerg Med. 2013 Oct;20(10):1050-4. Babl FE, Theophilos T, Palmer GM. Is there a role for intravenous acetaminophen in pediatric emergency departments? Pediatr Emerg Care. 2011 Jun;27(6):496-9. Bailey E, Worthington HV, van Wijk A, Yates JM, Coulthard P, Afzal Z. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth.Cochrane Database Syst Rev. 2013 Dec 12;(12):CD004624. Bearden DJ, Feinstein A, Cohen LL. The influence of parent preprocedural anxiety on child procedural pain: mediation by child procedural anxiety. J Pediatr Psychol. 2012 Jul;37(6):680-6. Berde CB, Sethna NF. Analgesics for the treatment of pain in children. N Engl J Med. 2002 Oct 3;347(14):1094-103. Brousseau DC, Duffy SJ, Anderson AC, Linakis JG. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004 Feb;43(2):256-62. Ciszkowski C, Madadi P, Phillips MS, Lauwers AE, Koren G. Codeine, ultrarapid-metabolism genotype, and postoperative death. N Engl J Med. 2009 Aug 20;361(8):827-8. Cornelissen L, Donado C, Kim J, Chiel L, Zurakowski D, Logan DE, Meier P, Sethna NF, Blankenburg M, Zernikow B, Sundel RP, Berde CB. Pain hypersensitivity in juvenile idiopathic arthritis: a quantitative sensory testing study. Pediatr Rheumatol Online J. 2014 Sep 6;12:39. Crews KR, Gaedigk A, Dunnenberger HM, Leeder JS, Klein TE, Caudle KE, Haidar CE, Shen DD, Callaghan JT, Sadhasivam S, Prows CA, Kharasch ED, Skaar TC; Clinical Pharmacogenetics Implementation Consortium. Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Clin Pharmacol Ther. 2014 Apr;95(4):376-82. Deaton T, Auten JD, Darracq MA. Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial. Am J Emerg Med. 2015 Jun;33(6):791-5. Dokko D. Best practice for fever management with intravenous acetaminophen in pediatric oncology. J Pediatr Oncol Nurs. 2015 Mar-Apr;32(2):120-5. Farion KJ, Splinter KL, Newhook K, Gaboury I, Splinter WM. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial. CMAJ. 2008 Jul 1;179(1):31-6. Finley GA, Kristjánsdóttir O, Forgeron PA. Cultural influences on the assessment of children's pain. Pain Res Manag. 2009 Jan-Feb;14(1):33-7. Friedrichsdorf SJ, Kang TI. The management of pain in children with life-limiting illnesses. Pediatr Clin North Am. 2007 Oct;54(5):645-72. Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial. Emerg Med Australas. 2009 Jun;21(3):203-9. Gandhi M, Thomson C, Lord D, Enoch S.  Management of Pain in Children with Burns. Int J Pediatr. 2010; 2010: 825657. Ganesh A, Gurnaney HG. Ultrasound guidance for pediatric peripheral nerve blockade. Anesthesiol Clin. 2009 Jun;27(2):197-212. Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1. Hadden KL, von Baeyer CL. Pain in children with cerebral palsy: common triggers and expressive behaviors. Pain. 2002 Sep;99(1-2):281-8. Harrison D, Bueno M, Yamada J, Adams-Webber T, Stevens B. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics. 2010 Nov;126(5):894-902. Hauer JM, Wical BS, Charnas L. Gabapentin successfully manages chronic unexplained irritability in children with severe neurologic impairment. Pediatrics. 2007 Feb;119(2):e519-22. Horeczko T, Mahmoud MA. The sedation mindset: philosophy, science, and practice. Curr Opin Anaesthesiol. 2016 Feb;29 Suppl 1:S48-55. Howard RF. Current status of pain management in children. JAMA. 2003 Nov 12;290(18):2464-9. Keck JF, Gerkensmeyer JE, Joyce BA, Schade JG. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. J Pediatr Nurs. 1996 Dec;11(6):368-74. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53. Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59–66. Liebelt EL. Assessing children's pain in the emergency department. Clin Pediatr Emerg Med. 2000; 1(4):260-269. Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM. A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children. Pediatrics. 2006 Oct;118(4):e1078-86. Lunoe MM, Drendel AL, Levas MN, Weisman SJ, Dasgupta M, Hoffmann RG, Brousseau DC. A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children. Ann Emerg Med. 2015 Nov;66(5):466-74. Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. 2006 Mar;16(3):258-65. Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005660. Maxwell LG, Malavolta CP, Fraga MV. Assessment of pain in the neonate. Clin Perinatol. 2013 Sep;40(3):457-69. Merry AF, Edwards KE, Ahmad Z, Barber C, Mahadevan M, Frampton C. Randomized comparison between the combination of acetaminophen and ibuprofen and each constituent alone for analgesia following tonsillectomy in children. Can J Anaesth. 2013 Dec;60(12):1180-9. Michelson KN, Steinhorn DM. Pediatric End-of-Life Issues and Palliative Care. Clin Pediatr Emerg Med. 2007 Sep; 8(3): 212–219. Miner JR, Kletti C, Herold M, Hubbard D, Biros MH. Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med. 2007 Oct;14(10):895-8. Moadad N, Kozman K1, Shahine R, Ohanian S, Badr LK. Distraction Using the BUZZY for Children During an IV Insertion. J Pediatr Nurs. 2016 Jan-Feb;31(1):64-72. Patniyot IR, Gelfand AA. Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review. Headache. 2016 Jan;56(1):49-70. Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, Mo: Mosby; 2011. Piaget J. Judgment and reasoning in the child. Harcourt & Brace. Oxford, England. 1928. Poonai N, Paskar D, Konrad SL, Rieder M, Joubert G, Lim R, Golozar A, Uledi S, Worster A, Ali S. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014 Nov;21(11):1183-92. Racoosin JA, Roberson DW, Pacanowski MA, Nielsen DR. New evidence about an old drug--risk with codeine after adenotonsillectomy. N Engl J Med. 2013 Jun 6;368(23):2155-7. Sheehy KA, Muller EA, Lippold C, Nouraie M, Finkel JC, Quezado ZM. Subanesthetic ketamine infusions for the treatment of children and adolescents with chronic pain: a longitudinal study. BMC Pediatr. 2015 Dec 1;15:198. Sheehy KA, Finkel JC, Darbari DS, Guerrera MF, Quezado ZM. Dexmedetomidine as an Adjuvant to Analgesic Strategy During Vaso-Occlusive Episodes in Adolescents with Sickle-Cell Disease. Pain Pract. 2015 Nov;15(8):E90-7. Sheppard JL. The application of Piaget's theory to physiotherapy. Aust J Physiother. 1977 Dec;23(4):133-40. Spanos S, Booth R, Koenig H, Sikes K, Gracely E, Kim IK. Jet Injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial. Pediatr Emerg Care. 2008 Aug;24(8):511-5. Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: assessment and nonpharmacological management. Int J Pediatr. 2010;2010. Stevens B, Yamada J, Lee GY, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD001069. Suresh S, Sawardekar A, Shah R. Ultrasound for regional anesthesia in children. Anesthesiol Clin. 2014 Mar;32(1):263-79. Taddio A, Shah V, Gilbert-MacLeod C, Katz J. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002;288(7):857. Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. Br J Surg. 2003 Jan;90(1):5-9. Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010 Nov;126(5):e1168-98. Tsze DS, von Baeyer CL, Bulloch B, Dayan PS. Validation of Self-Report Pain Scales in Children. Pediatrics. 2013 Oct; 132(4): e971–e979. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002 Nov;95(5):1224-9. Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: a pilot study. Emerg Med Australas. 2013 Apr;25(2):161-7   This post and podcast are dedicated to Sergey M. Motov, MD, FAAEM, for his integrity, hard-won expertise, humility, and innovation.  Thank you for making us better doctors, Sergey, and for getting us ever closer to a pain-free ED. Pediatric Pain Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

RSI delivered by EM clinicians is common place throughout the globe, in the UK however it still seems a contentious topic, with recent data showing only 20% of ED RSIs being performed by EM clinicians. I was lucky enough to be asked to talk at the ICS SoA 2016 conference on the topic of EM doctors carrying out RSI's in the UK and this podcast is a copy of that talk. I hope it provides some context both to UK practitioners and also to those from other countries, who may not understand what the big deal is all about. Simon References A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance.Randomized controlled trial. Kovacs G, et al. Ann Emerg Med. 2000 Acute airway management in the emergency department by non-anesthesiologists. Review article. Kovacs G, et al. Can J Anaesth. 2004 Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Mayo PH, et al. Crit Care Med. 2004 The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Reid C, et al. Emerg Med J. 2004 Rapid sequence induction of anaesthesia in UK emergency departments: a national census. Benger J, et al. Emerg Med J. 2011. Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations. Kerslake D, et al. Resuscitation. 2015 Systematic review and meta-analysis of first-pass success rates in emergency department intubation: Creating a benchmark for emergency airway care. Park L, et al. Emerg Med Australas. 2016 Scottish Intensive Care Society: RSI Difficult Airway Society Guidelines RCOA Anaesthesia in the Emergency Department Guidelines; Chapter 6.1 John Hinds on RSI at RCEM 2015 Belfast Draft; AAGBI Guidelines: Safer pre-hospital anaesthesia 2016 AAGBI Pre-hospital Anaesthesia Guideline 2009

Ep #21 Ketamine Induced Rapid Sequence Intubation with Faizan H. Arshad, MD @emscritcare Happy #EMSWeek #EMSStrong #EMSNation   SKEPTIC = Safety & Efficacy of Ketamine in Emergent Prehospital Tracheal Intubation – a Case Series   Brand new paper from Sydney HEMS on Ketamine and Shock Index in Annals of EM! http://www.annemergmed.com/article/S0196-0644(16)30002-6/abstract   Additional References: Carlson JN, Karns C, Mann NC, et al. Procedures performed by emergency medical services in the united states.Prehosp Emerg Care. 2015. Jacobs PE, Grabinsky A. Advances in prehospital airway management.International Journal of Critical Illness & Injury Science. 2014;4:57-64. Prekker ME, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea TD. The process of prehospital airway management: Challenges and solutions during paramedic endotracheal intubation.Crit Care Med. 2014;42:1372-1378. Wang HE, Kupas DF, Greenwood MJ, et al. An algorithmic approach to prehospital airway management.Prehospital Emergency Care. 2005;9:145-155. Mace SE. Challenges and advances in intubation: Airway evaluation and controversies with intubation.Emerg Med Clin North Am. 2008;26:977-1000. Combes X, Jabre P, Jbeili C, et al. Prehospital standardization of medical airway management: Incidence and risk factors of difficult airway.Acad Emerg Med. 2006;13:828-834. Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity. Br J Anaesth. 1996;76:663-667. Jackson APF, Dhadphale PR, callaghan ML, Alseri S. Haemodynamic studies during induction of anaesthesia for open-heart surgery using diazepam and ketamine. Br J Anaesth. 1978;50:375-378. Price B, Arthur AO, Brunko M, et al. Hemodynamic consequences of ketamine vs etomidate for endotracheal intubation in the air medical setting. Am J Emerg Med. 2013;31:1124-1132. Scherzer D, Leder M, Tobias JD. Pro-Con Debate: Etomidate or Ketamine for Rapid Sequence Intubation in Pediatric Patients. J Pediatr Pharmacol Ther. 2012;17:142-149. Bruder Eric A, Ball Ian M, Ridi S, Pickett W, Hohl C. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients.Cochrane Database of Systematic Reviews. 2015 Thompson Bastin ML, Baker SN, Weant KA. Effects of Etomidate on Adrenal Suppression: A Review of Intubated Septic Patients.Hospital Pharmacy. 2014;49:177-183. Arnold C. The promise and perils of ketamine research Ketamine began its life as an anaesthetic , but has enjoyed a recent renaissance as a potential. Lancet Neurol. 2013;12:940-941. Craven R. Ketamine. Anaesthesia. 2007;62:48-53. Perkins ZB, Gunning M, Crilly J, Lockey D, O’Brien B. The haemodynamic response to pre-hospital RSI in injured patients. Injury. 2013;44:618-623. Aroni F, Iacovidou N, Dontas I, Pourzitaki C, Xanthos T. Pharmacological Aspects and Potential New Clinical Applications of Ketamine: Reevaluation of an Old Drug. J Clin Pharmacol. 2009;49:957-964. Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation.J Emerg Med. 2010;38:622-631. Kohrs R, Durieux ME. Ketamine. Anesth Analg. 1998;87:1186-1193. Moy RJ, Clerc S Le. Trends in Anaesthesia and Critical Care Ketamine in prehospital analgesia and anaesthesia. Trends Anaesth Crit Care. 2011;1:243-245. Reich DL, Silvay G. Ketamine: an update on the first twenty-five years of clinical experience. Can J Anaesth. 1989;36(2):186-197. Porter K. Ketamine in prehospital care. Emerg Med J. 2004;21:351-354. Svenson JE, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007;25:977-980. Johansson J, Sjöberg J, Nordgren M, Sandström E, Sjöberg F, Zetterström H. Prehospital analgesia using nasal administration of S-ketamine--a case series. Scand J Trauma Resusc Emerg Med. 2013;21:38. Filanovsky Y, Miller P, Kao J. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. Can J Emerg Med. 2010;12:154-201. Himmelseher S, Durieux ME. Revising a Dogma: Ketamine for Patients with Neurological Injury? Anesth Analg. 2005;101:524-534. Kropf J a., Grossman MD, Genzlinger M a., Stoltzfus J, Stehly CD. 328 Ketamine versus Etomidate for Rapid Sequence Intubation in Traumatically Injured Patients: An Exploratory Study. Ann Emerg Med. 2012;60:S117. Angus DC, van dP. Severe sepsis and septic shock.N Engl J Med. 2013;369:840-851. Jabre P, Avenel A, Combes X, et al. Morbidity related to emergency endotracheal intubation-A substudy of the KETAmine SEDation trial. Resuscitation. 2011;82:517-522. Shafi S, Gentilello L. Pre-Hospital Endotracheal Intubation and Positive Pressure Ventilation Is Associated with Hypotension and Decreased Survival in Hypovolemic Trauma Patients: An Analysis of the National Trauma Data Bank. The Journal of Trauma: Injury, Infection, and Critical Care. 2005;59:1140–1147. Seymour CW, Band RA, Cooke CR, et al. Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study.J Crit Care. 2010;25:553-562. Williams E, Arthur a., Price B, Banister NJ, Goodloe JM, Thomas SH. 175 Ketamine versus Etomidate for Use in Helicopter Emergency Medical Services Endotracheal Intubation. Ann Emerg Med. 2012;60:S63-S64 Bruns, B, Gentilello, L, Elliott, A, Shafi, S. Prehospital Hypotension Redefined. The Journal of Trauma: Injury, Infection, and Critical Care. 2008;65:1217–1221. Seymour, CW, Cooke, CR, Heckbert, SR, et al. Prehospital Systolic Blood Pressure Thresholds: A Community-based Outcomes Study. Acad Emerg Med Academic Emergency Medicine. 2013;20:597–604. Kristensen AKB, Holler JG, Mikkelsen S, Hallas J, Lassen A. Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study.Critical Care. 2015;1:158. Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84:1500-1504. Salt PJ, Baranes PK, Beswick FJ. Inhibition of neuronal and extraneuronal uptake of noradrenaline by ketamine in the isolated perfused rat heart. Br J Anaesth. 1979;51:835-838. Sprung J, Schuetz SM, Stewart RW, Moravec CS. Effects of Ketamine on the Contractility of Failing and Nonfailing Human Heart Muscles in Vitro. Surv Anesthesiol. 1999;43:230-231. Kunst G, Martin E, Graf BM, Hagl S, Vahl CF. Actions of Ketamine and Its Isomers on Contractility and Calcium Transients in Human Myocardium. Anesthesiology. 1999;90:1363-1371. Lundy PM, Lockwood PA, Thompson G, Frew R. Differential Effects of Ketamine Isomers on Neuronal and Extraneuronal Catecholamine Uptake Mechanisms. Anesthesiology. 1986;64:359-363. Selde W. Push dose epinephrine. A temporizing measure for drugs that have the side-effect of hypotension.JEMS. 2014;39:62-63.   Sponsored by @PerfectCPR Apple Watch App with Audio and Haptic Feedback to Optimize Cardiac Arrest Training and Improve Quality of CPR Delivery PerfectCPR.com     Query us on Twitter: www.twitter.com/EMS_Nation Like us on Facebook: www.facebook.com/prehospitalnation   Wishing Everyone a safe tour! ~Faizan H. Arshad, MD @emscritcare www.emsnation.org