Podcasts about emla

Fishhook injuries are common, surprisingly nuanced, and honestly a little intimidating until you've removed a few. In this first episode of our Minor Procedures series, we'll reel in the essentials of pediatric fishhook removal, helping you take the bait on four classic removal techniques, procedural planning, anesthesia strategies, and post-removal management. We'll discuss when to pull back, when to advance, when not to get hooked on a single technique, and how to avoid turning a simple procedure into the one that got away. Along the way we'll cover sedation, antibiotics, wound care, and practical pearls to help you land these cases with confidence. Learning Objectives Compare and select among the four major fishhook removal techniques based on hook characteristics, depth of penetration, and anatomic location. Apply evidence-based approaches to analgesia, anxiolysis, procedural sedation, and post-removal management for pediatric fishhook injuries. Identify situations requiring escalation of care, including ocular involvement, contaminated water exposure, tendon or joint involvement, and circumstances where routine management may not be sufficient. References Gammons MG, Jackson E. Fishhook removal. Am Fam Physician. 2001;63(11):2231-2236. Prats M, O'Connell M, Wellock A, Kman NE. Fishhook removal: case reports and a review of the literature. J Emerg Med. 2013;44(6):e375-e380. doi:10.1016/j.jemermed.2012.11.058 Doser C, Cooper WL, Ediger WM, et al. Fishhook injuries: a prospective evaluation. Am J Emerg Med. 1991;9(5):413-415. doi:10.1016/0735-6757(91)90204-w Transcript This episode used an AI-generated transcript created in Descript as an initial draft. The transcript was subsequently edited, expanded, and refined by the author with assistance from OpenAI's ChatGPT (GPT-5.5). Final editorial decisions and content responsibility remain with the author. Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I'm your host, Brad Sobolewski, and today we're gonna start a new series on minor procedures. These are the types of procedures that we perform all the time in the emergency department. They're not the subject of multicenter trials or big keynote lectures, but these are the things that patients and families remember, and trust me, they will remember them whether you do them well or not. First up, fishhook removal. So I'm hoping to reel in some listeners with this one, and so hopefully you'll take the bait, and by the end of this episode you'll understand exactly what angle I'm coming from. And hopefully I'm just not trying to make a bass of myself. So anyway, fishhook removal sounds really simple until you actually start doing it. There's not just one technique. There are four classic approaches, and I'll talk about them all, and which one you choose depends on the hook, whether there's a barb, how deep it is, where it's located, your personal experience with different techniques. Fishhook injuries in children are usually minor and most commonly involve the hands and head, though I've seen them stuck in other body parts as well. Most can be managed in the emergency department or urgent care setting with local anesthesia and basic equipment Of course, if there's concern for tendon involvement, joint penetration, neurovascular compromise, if it's anywhere near the eyeball, you should stop and rethink your plan. You know, so ortho, if it's embedded deeply in a joint, um, anything that involves the eye itself isn't necessarily an emergency department procedure, and I'm not talking about the eyebrow, I'm talking about the globe. Fortunately, that's very rare, but that's definitely an ophthalmology conversation. And so before you even think about removing, you need to understand the hook. Is this a single hook or is this a treble hook? A treble hook is a type of fishing hook that has three individual hooks and barbs arranged in a triangular formation, and they're all fused to a single shank and eye. The eye is where the line gets tied to the hook. Is it freshwater or saltwater? How long has it been there? Is it an old rusty one that was sitting in your garage? Was it underwater for a few hours and then it got hooked in the skin? And honestly, how cooperative is the kid gonna be? Because unlike actual fishing, this is one of the procedures where patience beats blunt force. So the simplest technique is retrograde removal. This is exactly what families think you're gonna do before you walk in the room. You know, just pull it out the way it went in. But that's not how hooks are designed. They have the barb. They're designed to stay in the fish. So most of the hooks that I've removed are barbed hooks, and so you can't just back them out. If you try to pull a hook out the way it came in, it's gonna catch and tug on the tissue, it's gonna lead to more pain, bleeding and tissue distortion and not really gonna get you anywhere. So just pulling it out doesn't work, and family probably would have already tried that at home. The technique I end up using most often is advance and cut. And it kind of sounds wrong the first time you explain it to a family because your solution to removing the hook is to continue to advance the hook, but mechanically, this makes the most sense. So you advance the point of the hook through the skin until the barb exits completely, then use either really good trauma shears or heavy wire cutters to cut the hook in between the shank and the barb. If it's in a location where you have, uh, enough room, I like to hold a hemostat real close to the skin, grabbing the hook. Then I cut near the barb, get the pointy part out of the way, remove the hemostats, and then back it through the skin. This is considered the most reliable technique, and in most reviews it's described as being nearly universally successful, even for larger hooks. In children, I think this needs to be the go-to technique because success matters. You just gotta get it done on the, the first attempt. Kids don't tolerate multiple failed attempts very well. Um, obvious downside is that you create a second puncture wound, but in practice, that puncture is usually controlled and much less traumatic than repeated unsuccessful pulling. Depending on where the skin's at, you may actually need to put a little bit of tension or pressure against the skin to get that hook to poke through. Ultimately, this advance and cut method is the one that you should spend the most time learning and teaching to your trainees. The string yank technique is the one that often is seen at summer camps and on YouTube videos. You loop string or heavy suture or even fishing line around the bend of the hook, apply downward pressure to the shank to disengage the barb, and then pull quickly in line with the shaft of the hook. When it works, it yanks it out almost instantly. That's why the YouTube videos are popular. One second there's a fishhook in the finger, and the next there isn't. The advantage is that this can sometimes just be performed without anesthesia and can even be done at home. The disadvantage is obvious if you work with children. This requires cooperation. Younger kids, anxious kids, a treble hook, something that's deeply embedded, like this isn't gonna work all that well, and it's, again, less reliable with bigger and deeply embedded hooks. The last technique is needle cover. This one gets less attention. It seems elegant, but in practice it's actually pretty hard to do, especially in smaller kid parts. You insert an 18-gauge needle alongside the entry tract until the bevel of that needle covers the barb, and then pull both out together The advantage is that you avoid creating a second puncture wound, and you can minimize tissue trauma. The disadvantage is it's really complex technically. Maintaining alignment of both the hook and needle can be tricky because they sort of like roll and move around. And if you want to do this one, it's probably easier for smaller and medium-sized hook rather than larger embedded or treble hooks. And as you might imagine in the literature, there's not really any randomized trials comparing these techniques. Most of what we know comes from prospective observational studies, case series, procedural experience, and expert review. Advance and cut seems to have the broadest success across scenarios. String yank does earn some points for field use and avoiding local numbing. Needle cover is hard to do, but if the parent is absolutely adamant that you don't create a second hole, then that's probably your best option. And as with any procedure, you should probably be facile in multiple techniques in case the first one doesn't work. You don't just want to stand there and flounder. Anyway, most fishhook removals in children can be done with local anesthesia alone. One percent Lido with or without epi is usually enough. Depending on the location, you may need to do a digital block or a field block instead of just injecting directly around the hook because local infiltration itself can distort the anatomy and actually make removal harder. So that's why I like blocking the digit or doing a little bit of a field block around it. If you have time, a topical anesthetic before local infiltration can be a nice gesture. LMX or EMLA can be really helpful, especially for really anxious kids or kids who are escalating before you even start setting up. They take about forty to sixty minutes. About forty-five minutes is probably ideal. So if you can get that put on in triage, that's actually a, a great technique. So if you know you're going to inject to numb to get the fishhook out, and you need a little bit of extra time to get child life or other personnel in the room, by all means, put a topical anesthetic there. It only absorbs into the outer two millimeters, but it'll help with the poke, not necessarily the burning that happens once the lidocaine is in the tissue. And now that we've talked about pain, I think it's also important to talk about anxiolysis. Most kids that have embedded fishhooks don't need full procedural sedation. If it's right next to the eye, like in the eyelid, then that might be beneficial, especially in a preschool-aged kid or younger. Plenty of them do need some anxiolysis. Um, intranasal or oral midazolam is probably, uh, the most popular option. It's got rapid onset in about twenty minutes, no IV, some amnesia. Recent pediatric data suggests that point four or point five milligrams per kilogram may perform better than lower doses, uh, for the intranasal. If you've got nitrous oxide, that's another nice option for cooperative kids. It provides anxiolysis and analgesia with rapid recovery and a very low rate of adverse respiratory events. Fishhook removal is actually one of those procedures where nitrous can feel disproportionately helpful because the procedure itself is often quick, and the hardest part is just reducing the fear and helping the kid hold still for about thirty to sixty seconds. I think ketamine still has a role. I alluded to when I might use that earlier. Occasionally, you walk into the room and then there's a deeply embedded treble hook, a really anxious child, a failed attempt prior to you being there. And ultimately, yes, IV procedural sedation with ketamine should be on the table, and it's as always an excellent option. And never, ever underestimate distraction. Hopefully, you work in a place where there are child life specialists because they are wonderful. They are magic. But you've got videos, you know, music, VR, parents. I mean, sometimes the difference between success and failure is a working iPad. And then finally, the question of antibiotics. So fishhook removal does not automatically equal a course of antibiotics. A prospective series of one hundred fishhook injuries found prophylactic antibiotics were unnecessary for uncomplicated soft tissue injuries that didn't involve the cartilage or tendon. So if you've got a contaminated wound, a delayed presentation, you know, it was already in an established infection, though I've never actually seen someone impale a fishhook into an area of cellulitis. There's tendon involvement, joint involvement, or, you know, gross water exposure. Well, then maybe consider antibiotics. Freshwater injuries do raise concern for organisms like Aeromonas. Saltwater injuries introduce concern for Vibrio species and occasionally Mycobacterium marinum enters the conversation or the tissue. Um, saltwater injuries are often treated with doxycycline plus a third-generation cephalosporin. You recognize the doxy decisions in younger children require some additional consideration. Freshwater injuries could push you towards broader Gram-negative coverage, but, but honestly, for most fishhook injuries, especially in healthy children, you're just dealing with skin flora. So once I get the hook out, I make sure there's no other retained foreign bodies, like little pieces of the hook or little pieces of the barb. I irrigate with saline or tap water, maybe a hundred mLs for a smaller hook, more for bigger hooks or grossly contaminated wounds. Make sure that there's full neurovascular function and normal range of motion. Antibiotic ointment, simple dressing, update their tetanus shot if it's not been within five years, and explain to the family that the good news is that this is really a forgiving injury most of the time. Once the hook is out, these generally heal really well. We don't need to suture them back up. We're not worried about long-term damage. Tell the parents to watch out for increasing redness, worsening pain, pus drainage, fever, or other systemic symptoms, trouble moving the area, especially if it was around a digit, you know, numbness or anything else that makes you concerned that infection has started instead of healing. Families will almost always ask jokingly when they can fish again. Honestly, usually pretty quickly. Just don't put the wound under water until it's healed, and don't stand directly behind whoever is casting. And now for some take-home points. Fishhook removal is a simple and straightforward procedure where technique really matters. You have to know what type of hook is embedded in the skin. Retrograde does work for superficial or barbless hooks, but most fishhooks that I've seen have barbs because they are designed to stay in the fish. Advance and cut is probably the most broadly successful technique. String yank works if you're a YouTuber. Needle cover is really, I think, only for those scenarios where the family does not want a second hole. It's really actually hard to do. Local anesthesia is enough for most kids, so injecting with lidocaine. If you have time, LMX or EMLA helps with the poke a little bit. Routine antibiotics are not usually necessary. And if there's ocular involvement or if it's in a joint, call an ophthalmologist or an orthopedist. Honestly, this is one of those procedures that's really satisfying once you get comfortable with it. I love doing it with our residents and trainees. Families come in expecting something dramatic, and by the time they leave, they're surprised by how straightforward it was. And I guarantee that this is a story that they will tell for years and years. And if you do a good job and make it a good experience and perhaps even a lighthearted one, they are going to remember that. And yeah, you'll be part of somebody's fishing story. So I hope you did enjoy this first episode on minor procedures. I'm gonna do additional ones like these along the way because, you know, I think that they don't get a lot of love when it comes to traditional education. If you've got any ideas for future procedures or topics, please send them my way. As the kids would say, like, rate, and review. If you leave a review on your favorite podcast site, that would really help other people discover the show. I podcast because I think it's a great way to teach, and I've been doing so since 2013. And yes, you can remove a fishhook. Don't let this straightforward procedure become the one that got away. For PEM Currents: The Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.  

It's auction week, baby! Join David and Ryan LIVE (or after the fact for those of you who aren't insane) to experience the March 2026 Propstore sale and all the things the guys are bidding on, not bidding on, should be bidding on, or are selling so they can bid on other things, or pay off their large Propstore debts. It's categories time! Which Mel Gibson prop is Dave going to talk about this time? And what /is/ the worst Prometheus prop? Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/ Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

It's auction week, baby! Join David and Ryan LIVE (or after the fact for those of you who aren't insane) to experience the March 2026 Propstore sale and all the things the guys are bidding on, not bidding on, should be bidding on, or are selling so they can bid on other things, or pay off their large Propstore debts. It's categories time! Which Mel Gibson prop is Dave going to talk about this time? And what /is/ the worst Prometheus prop? Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/ Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

The boys are back, ready to buy props and chew bubblegum -- and they're all out of bubblegum. David and Ryan dive into this brand-spanking-new season with a catalog episode, this one covering Propstore's March 25-27 Los Angeles auction. We've got HOTD updates and storage facility updates as well as all of the guys' Favorite Things from Day 1 of the auction, with everything from Black Panther helmets to the finest Terminator jacket ever to come to market. There are C-3P0 heads, shark-killing spearguns and shark-catching fishing rods, golden tickets, Ryan's very own dazzling clapperboard collection, an incredible Frank Frazetta painting, Val Kilmer licenses, Last Boyscout props for Dave, and of course... the anal-birthing savanna beast from Ace Ventura: When Nature Calls. Kinda hot in these rhinos! Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/ Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

The boys are back, ready to buy props and chew bubblegum -- and they're all out of bubblegum. David and Ryan dive into this brand-spanking-new season with a catalog episode, this one covering Propstore's March 25-27 Los Angeles auction. We've got HOTD updates and storage facility updates as well as all of the guys' Favorite Things from Day 1 of the auction, with everything from Black Panther helmets to the finest Terminator jacket ever to come to market. There are C-3P0 heads, shark-killing spearguns and shark-catching fishing rods, golden tickets, Ryan's very own dazzling clapperboard collection, an incredible Frank Frazetta painting, Val Kilmer licenses, Last Boyscout props for Dave, and of course... the anal-birthing savanna beast from Ace Ventura: When Nature Calls. Kinda hot in these rhinos! Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/ Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

David and Ryan get on the blower to cover the categories and days 2 and 3 of the Propstore auction, which kicks off today, December 5th! They cover their tried and true 'live show' categories including the little things they love that might fly beneath the radar as well as what they think the weirdest thing in the auction might be. And: what would their kids love? What would their wives hate? What would they buy for each other? What really /is/ the worst Prometheus prop? Plus, a guest listener joins the show to discuss his purchase of a replica costume that ended up being the real deal! Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

David and Ryan get on the blower to cover the categories and days 2 and 3 of the Propstore auction, which kicks off today, December 5th! They cover their tried and true 'live show' categories including the little things they love that might fly beneath the radar as well as what they think the weirdest thing in the auction might be. And: what would their kids love? What would their wives hate? What would they buy for each other? What really /is/ the worst Prometheus prop? Plus, a guest listener joins the show to discuss his purchase of a replica costume that ended up being the real deal! Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/ Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

On a very special, unscheduled, unsponsored episode of the podcast, David and Ryan hop on the mics to review the September 2025 Propstore auction. What did they win? What did they lose? What did they think of the results? Did David win a lightsaber? Did Ryan decide what to bid on? Hint: someone made some dough, and someone spent too much. Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

On a very special, unscheduled, unsponsored episode of the podcast, David and Ryan hop on the mics to review the September 2025 Propstore auction. What did they win? What did they lose? What did they think of the results? Did David win a lightsaber? Did Ryan decide what to bid on? Hint: someone made some dough, and someone spent too much. Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/ Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.

David and Ryan get on the blower to cover the categories and days 2 and 3 of the Propstore auction, which kicks off tomorrow, September 4th! Hear all about David's anxiety over Darth Vader's lightsaber and Ryan's over the sheer amount of Keaton Batman stuff he has look at before the auction really even begins. They discuss the little things they love that might fly beneath the radar as well as what they think the weirdest thing in the auction might be. And: what would their kids love? What would their wives hate? What would they buy for each other? Who is bidding on terrible Dean Cain props? What really /is/ the worst Prometheus prop? Oh yeah, and another update on fakes. They're comin' out of the walls, man!! Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

David and Ryan get on the blower to cover the categories and days 2 and 3 of the Propstore auction, which kicks off tomorrow, September 4th! Hear all about David's anxiety over Darth Vader's lightsaber and Ryan's over the sheer amount of Keaton Batman stuff he has look at before the auction really even begins. They discuss the little things they love that might fly beneath the radar as well as what they think the weirdest thing in the auction might be. And: what would their kids love? What would their wives hate? What would they buy for each other? Who is bidding on terrible Dean Cain props? What really /is/ the worst Prometheus prop? Oh yeah, and another update on fakes. They're comin' out of the walls, man!! Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

It's Q4 and another massive auction season is nigh upon us. The fun kicks off with Propstore's September live auction and 1,400+ lots from all your favorite (and some unfavorite) films and TV shows. Join David and Ryan as they page through Day 1 of the sale and cover everything from 2010 to Zardoz and everything in between, including Clockwork orange canes, wonderful Batman toys, Indy whips (and belts), Jaws' jaws clappers, Sauron helmets, flashy things, hippie-slaying flamethrowers, the Rocketeer, Genesis devices, Picard's flute (Round 3 -- or is it 4?) and, of course, Darth Vader's Lightsaber. Join the guys for all the jokes and insights you've come to love and also for a very special Stuff Dreams Are Made Of career retrospective on Dean Cain. Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

It's Q4 and another massive auction season is nigh upon us. The fun kicks off with Propstore's September live auction and 1,400+ lots from all your favorite (and some unfavorite) films and TV shows. Join David and Ryan as they page through Day 1 of the sale and cover everything from 2010 to Zardoz and everything in between, including Clockwork orange canes, wonderful Batman toys, Indy whips (and belts), Jaws' jaws clappers, Sauron helmets, flashy things, hippie-slaying flamethrowers, the Rocketeer, Genesis devices, Picard's flute (Round 3 -- or is it 4?) and, of course, Darth Vader's Lightsaber. Join the guys for all the jokes and insights you've come to love and also for a very special Stuff Dreams Are Made Of career retrospective on Dean Cain. Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

The Stuff Dreams Are Made Of is back with another live episode (covering Propstore's March 26-28 auction)! David and Ryan cover their (in)famous categories, shouting out everything from their favorite "small" pieces in days 2 and 3 to the worst Prometheus prop in the auction. They fake buy each other gifts, pick out stuff to delight or antagonize their wives, and talk about the things their kids would want them to buy. Finally, the guys tell each other what they should be bidding on and talk about what they might actually raise the paddle for in the auction. It's a live stunt spectacular! Catalog: https://propstoreauction.com/auctions/catalog/id/449 Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

The Stuff Dreams Are Made Of is back with another live episode (covering Propstore's March 26-28 auction)! David and Ryan cover their (in)famous categories, shouting out everything from their favorite "small" pieces in days 2 and 3 to the worst Prometheus prop in the auction. They fake buy each other gifts, pick out stuff to delight or antagonize their wives, and talk about the things their kids would want them to buy. Finally, the guys tell each other what they should be bidding on and talk about what they might actually raise the paddle for in the auction. It's a live stunt spectacular! Catalog: https://propstoreauction.com/auctions/catalog/id/449 Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

Another season, another Propstore auction. David and Ryan dive into the catalog for Propstore's first of three EMLA auctions of 2025, this one taking place from March 26 through the 28th in Los Angeles. This episode covers "a few of our favorite things" as the guys highlight the most interesting lots from day 1 of the 3-day auction. Join them for everything from fusion reactors to X-Files costumes! They've got Batman costumes, giant matte paintings, 100-year-old tramp boots, Conan swords, Commando vests, Blunt exo-suits, human skin books, ZF-1s, galaxy quests, ghost traps, wizard's robes, Dragonslaying equipment, stop-motion Martians (shut up, Dave), Pee-Wee's pals, and of course, expensive Star Wars props to drive Dave insane (shut up, Ryan)! Catalog: https://propstoreauction.com/auctions/catalog/id/449 Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

Another season, another Propstore auction. David and Ryan dive into the catalog for Propstore's first of three EMLA auctions of 2025, this one taking place from March 26 through the 28th in Los Angeles. This episode covers "a few of our favorite things" as the guys highlight the most interesting lots from day 1 of the 3-day auction. Join them for everything from fusion reactors to X-Files costumes! They've got Batman costumes, giant matte paintings, 100-year-old tramp boots, Conan swords, Commando vests, Blunt exo-suits, human skin books, ZF-1s, galaxy quests, ghost traps, wizard's robes, Dragonslaying equipment, stop-motion Martians (shut up, Dave), Pee-Wee's pals, and of course, expensive Star Wars props to drive Dave insane (shut up, Ryan)! Catalog: https://propstoreauction.com/auctions/catalog/id/449 Email: dreamsaremadeofpodcast@gmail.com SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Bluesky https://bsky.app/profile/propspodcast.bsky.social SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

These are a few of our favorite things!  It's auction season yet again and the Stuff Dreams Are Made Of has all your delicious and nutritious coverage of the big event in London. We have full-size power loader arms, James Cameron's Aliens script, Batman costumes, Dirk Diggler paintings, the Costumi D'Arte collection, including Cleopatra and a bunch of spaghetti Westerns, Maximus gear, Marauders Maps, ceremonial staffs, McGinnis paintings, full-size Kurgans, a Princess Bride archive, Yoda sticks, Tron helmets, McReady hats, and a T2 Colt pistol (deactivated, of course).  Join the guys for part one of their Propstore November London auction coverage!  Excelsior! Link to catalog PDF to follow along: https://content.propstore.com/auction/emlauk24/WebView/EMLA-UK_FALL_2024_PROPS_WEB_HI.pdf SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Threads https://www.threads.net/@propspodcast SDAMO - Twitter https://twitter.com/propspodcast?lang=en SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

These are a few of our favorite things!  It's auction season yet again and the Stuff Dreams Are Made Of has all your delicious and nutritious coverage of the big event in London. We have full-size power loader arms, James Cameron's Aliens script, Batman costumes, Dirk Diggler paintings, the Costumi D'Arte collection, including Cleopatra and a bunch of spaghetti Westerns, Maximus gear, Marauders Maps, ceremonial staffs, McGinnis paintings, full-size Kurgans, a Princess Bride archive, Yoda sticks, Tron helmets, McReady hats, and a T2 Colt pistol (deactivated, of course).  Join the guys for part one of their Propstore November London auction coverage!  Excelsior! Link to catalog PDF to follow along: https://content.propstore.com/auction/emlauk24/WebView/EMLA-UK_FALL_2024_PROPS_WEB_HI.pdf SDAMO - Instagram https://www.instagram.com/propspodcast/ SDAMO - Threads https://www.threads.net/@propspodcast SDAMO - Twitter https://twitter.com/propspodcast?lang=en SDAMO - Facebook https://www.facebook.com/propspodcast/ SDAMO - TikTok https://www.tiktok.com/@props.podcast David Mandel - Instagram https://www.instagram.com/davidhmandel/

Today is a longer than usual episode—something we thought about breaking into two chunks, but—just as Jessica hates requesting a 50-page partial, getting to a cliffhanger, and having to wait for more—we figured we'd bring you everything, the full episode, all at once. This is an episode that goes deep into the dynamics between authors, agents, the industry, and what authors can reasonably expect (and how to get it). The beginning is an interview on referral-only agencies, publishing norms, and how Jo found Tricia, her perfect match. And around 20 mins through, we pivot to what a writer can reasonably expect of an agent, and how to get it. We love to think of you, our listeners, while you are out in the world doing things. But if you happen to, say, be driving a minivan of neighborhood kids while you're listening, please note that this episode mentions several adult themes (including a notable mention of blue pills for adult males). If you get stuck with awkward questions, well—you've been warned. Jo Wu is an author born and raised in the San Francisco Bay Area, where she studied Biology and Creative Writing at UC Berkeley. Her works explore fairy tales, Chinese and Taiwanese mythology and identity, gothic tropes, and uplifting narratives. Some of her notable works have been published in Uncanny Magazine, Insignia 2020: Best Asian Fantasy Stories, and People of Color Destroy Lovecraft. Her short story, “Devoured by Envy,” was praised by Publishers Weekly as “the most Gothic of the successful stories” from the gothic romance anthology Darker Edge of Desire. When writing, she can be found accompanied by a plethora of goth mugs constantly refilled with green tea, while blasting a mix of metal and orchestral scores. When she is not writing, she will be sewing her next costume, deadlifting her next powerlifting goal, and auditioning for voiceover gigs. Jo is proudly represented by Tricia Lawrence of Erin Murphy Literary Agency. Find Jo online: https://jowu.co/ https://twitter.com/jo_wu_author Tricia is the "Pacific Northwest branch" of EMLA—born and raised in Oregon, and now lives in Seattle. After 16 years of working as a developmental and production-based editor (from kids books to college textbooks, but mostly college textbooks), she joined the EMLA team in March 2011 as a social media strategist and began working as an agent in October 2011. As senior agent, Tricia represents picture books/chapter books that look at the world in a unique and unusual way, with characters that are alive both on and off the page, and middle grade and young adult fiction and nonfiction that offers strong worldbuilding, wounded narrators, and stories that grab a reader and won't let go. Tricia loves hiking/walking/running, camping out in the woods with her family (her husband and their dogs), and collecting rocks. She loves BBC America and anything British. She has way too many books and not enough bookshelves. She's obsessed with pattern and color and is always listening to music (playlists for every situation and project) and lately has spent her spare time draping and fitting a half-size mannequin the size of a doll (this after binge-watching all of Project Runway). www.trishlawrence.com You can find Tricia on Twitter @authorblogger. She accepts queries by request or referral, or from people who have attended conferences where she part of the faculty via the contact page on EMLA or the contact page at her website. Find Tricia: https://trishlawrence.com/about/ https://emliterary.com/about.php

This dynamic agent/author duo is a delight to interview, and we learned so much. Jennifer A. Nielsen and Joan Paquette were a fundamental part of building each other's careers, and their combined wisdom and collaboration blew us away. We had way too much fun with  Jennifer A. Nielsen's series of interviews with costars, agent Ammi-Joan Paquette, and editor Lisa Sandell. (Stay tuned for part 2.)  Get the inside scoop on a healthy agent / author relationship, and learn so much about an amazingly prolific author-agent partnership. Jennifer A. NielsenNew York Times Bestselling author, Jennifer Nielsen, was born and raised in northern Utah, where she still lives today with her family, a dog that won't play fetch, and a cat that hallucinates. She is the author of The Ascendance series, beginning with THE FALSE PRINCE; the TRAITOR'S GAME series, the historical novels, RESISTANCE, A NIGHT DIVIDED,  WORDS ON FIRE, RESCUE, and several other titles. She loves chocolate, old books, and lazy days in the mountains. Jennifer is the founder of the Book Drop campaign.Ammi-Joan PaquetteJoan is a Senior Agent with EMLA, working from her home office in Massachusetts. She represents all forms of children's and young adult literature, but is most excited by a strong lyrical voice, tight plotting with surprising twists and turns, and stories told with heart and resonance that will stand the test of time. Joan is also the author of numerous books for children, most recently the Princess Juniper series, the picture books Ghost in the House, Elf in the House, Bunny Bus, and The Tiptoe Guide to Tracking Fairies, and the "non-fiction with a twist" series Two Truths and a Lie, co-written with Laurie Ann Thompson, and The Train of Lost Things. Please help support MG Book Party Podcast by purchasing books by these amazing authors through our affiliate links at no additional cost to you.Jennifer A. Nielsen:The Ascendance Trilogy: The False Prince, The Runaway King, The Shadow ThroneThe Captive KingdomThe Shattered CastleRescueResistanceA Night DividedThe Mark of the ThiefAmmi-Joan Paquette:Ghost in the HouseBunny BusPrincess Juniper of the HourglassTwo Truths and a Lie: Histories and MysteriesAs always, please feel free to connect with Heather and  Cheryl in the following places:www.CherylCaldwellAuthor.comwww.HeatherClarkBooks.comPreorder Heather's debut middle grade novel, LEMON DROP FALLS on Amazonwww.MGBookParty.comTwitter: @CherylCaldwell, @HClarkWrites, @MGBookPartyInstagram: @SaltyQuills, @HeatherClarkBooks, @MGBookPartyClubhouse: @CherylCaldwell, @HClarkWritesOr Join MGBookParty on Clubhouse here.

Janáčkova filharmonie Ostrava uzavřela svou 67. sezónu. Byla však první, která proběhla ve zcela jiných podmínkách. Spolu s omezeními, a nucenými změnami se však  vyskytovaly i nové příležitosti.

Janáčkova filharmonie Ostrava uzavřela svou 67. sezónu. Byla však první, která proběhla ve zcela jiných podmínkách. Spolu s omezeními, a nucenými změnami se však vyskytovaly i nové příležitosti.

Janáčkova filharmonie Ostrava odhalila svým příznivcům kompletní program nadcházející sezóny. Vstoupí do ní v čele s novým šéfdirigentem.

Janáčkova filharmonie Ostrava odhalila svým příznivcům kompletní program nadcházející sezóny. Vstoupí do ní v čele s novým šéfdirigentem.

Emla Cream

Cyclines don't cause pseudotumor cerebri(?) - Post-cryotherapy EMLA decreases pain - Women with cancers in the mid-face are less satisfied - Patient comfort level with the TBSE - 2cm margins safe for thick melanomas at 20 years - Dermasphere clip show!

Laurie Ann Thompson is a former software engineer who now writes for children and young adults to help her readers—and herself—make better sense of the world. She strives to write nonfiction that gives wings to active imaginations and fiction that taps into universal human truths. She lives near Seattle, Washington, and is an active member of the Society of Children’s Book Writers and Illustrators (SCBWI.) Her books include award winning BE A CHANGEMAKER, EMMANUELS'S DREAM, and her new series TWO TRUTHS AND A LIE. http://lauriethompson.com/   Ammi-Joan Paquette is a Senior Agent with Erin Murphy Literary Agency, working from her home office in Massachusetts. She represents all forms of children's and young adult literature, but is most excited by a strong lyrical voice, tight plotting with surprising twists and turns, and stories told with heart and resonance that will stand the test of time. An EMLA client herself, Joan is also the author of numerous books for children, including co-writing TWO TRUTHS AND A LIE. with Laurie Ann Thompson. Her next novel, the magical adventure The Train of Lost Things, is forthcoming from Philomel in March 2018. https://emliterary.com/index.php   Th is a copyrighted podcast solely owned by the Authors on The Air Global Radio Network LLC

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

Aspectos prácticos y forma de elaboración del gel EMLA reforzado empleando como base el gel de polietilenglicol

Have you ever been in any of these situations? ⇒   You have a stable child who just needs fluids, but no laboratory tests ⇒   You’ve tried PO hydration, to no avail, despite anti-emetics ⇒   You’re poking the stable, but dehydrated child repeatedly without success What now? Hypodermoclysis, otherwise known as subcutaneous rehydration. [Insert Player] Clysis comes from the same Greek word that “a flood” – hypodermoclysis refers to flooding the subcutaneous space with fluid, so that it can be absorbed systemically. Sound far-fetched? Well, it turns out, what is old is new again. In 1913, Dr Day first described this technique for a child with severe diarrhea who could not tolerate fluids by mouth. Hypodermoclysis then began to gain popularity with a peak of use in the 1940s, until an innovative breakthrough in 1950. Dr David Massa, a resident anesthesiologist at the Mayo clinic, invented the first catheter-over-needle apparatus. With increasing safety and ready access of IV catheters, IV quickly overshadowed SC. The subcutaneous route of hydration has also been used effectively in geriatric and palliative care for decades, and it is only now beginning to gain popularity again in its original population: children. So, how does it work? In a nutshell, you place a butterfly needle or angiocatheter in the subcutaneous space and you run fluids into it. The tissues quickly absorb the fluids, making them available systemically. That’s it. Everything else is just finesse. The ideal candidate for hypodermoclysis is the stable patient, with mild to moderate dehydration who fails a trial of fluids by mouth, or who needs a bridge to gaining IV access later, after a slow subcutaneous fluid bolus is given. Ok, so how do you do it? Place a topical anesthetic cream, such as EMLA, cover with occlusive dressing (IV dressing), wait 15-20 min "Pinch an inch" of skin anywhere, but the most practical site in young children is between the scapulae Insert a 25-gauge butterfly needle or 24-gauge angiocatheter (preferred by the author), secure Inject 150 U hyaluronidase SC, if available Infuse 20 mL/kg isotonic solution over one hour, repeat as needed or use "bolus" as bridge to IV access You can set the line to gravity, and if it is dripping in, you may leave it be. If you see a very slow drip by gravity, or worse, nothing is dripping, you can set the line on a pump, to deliver up to 20 mL/kg over an hour. Infusion at this rate optimizes the balance we want in minimal discomfort while maximizing the flow rate. This is not a “bolus” in the true sense – but then, when you compare it to the alternative – like IV therapy – and we see a time and cost savings.  Dr Mace and colleagues in the American Journal of Emergency Medicine report substantially decreased cost and ED length of stay when comparing the material and human resources needed to place an IV in a squirmy young child, compared with a simple subcutaneous stick. There will be swelling There will be swelling – that is the goal. It is really painless, and your patient may lie down on his back with the pump going – it is actually pretty comfortable for most children and adults to do. Here’s a tip – since there will be swelling, we want to be careful about how we secure the line, so how you tape it down to the skin is important – we want to avoid a pulling sensation, which can be the beginning of the end of the tolerance for the procedure.  Cover that with an occlusive dressing, as you would an IV site. The footprint of the occlusive dressing is relatively small, so it will travel up on top of the subcutaneous mound you’re creating. As the line exits the occlusive patch, place a thin layer of gauze between the skin and the IV tubing, so that the tubing doesn’t press into the skin. Then—as far away from the puncture site as possible—tape it down securely. The idea is not to tape on the growing mound itself, because the mound may pull at the anchored skin and set a nuclear chain reaction of annoyance and restlessness – and potentially a failed procedure. The swelling will look indurated, a pinkish red.  It’s not an allergic reaction: even with the old preparations of hyaluronidase, allergic reactions were rare, and now they are very rare with the recombinant preparation. It is supposed to swell and look ugly. The subcutaneous tissues will swell to a point where you have a steady state fluid administration rate, and as soon as you stop the infusion, the remaining fluid will start to subside as it is absorbed. A Bridge to IV Therapy? Kuensting et al. in the Journal of Emergency Nursing in 2013 compared subcutaneous fluid infusion with intravenous fluid infusion in children with difficult IV access. They found the mean time from order entry to subcutaneous fluid infusion to be 20 min, compared to the failed IV access group with an average infusion start time of 1.5 hours. The latter group eventually received subcutaneous fluids.  The investigators also found a shorter ED length of stay in the subcutaneous group. In the same study, a subgroup received subcutaneous fluids initially, and later an IV. They found a trend in ease of IV access after subcutaneous fluid therapy. In other words, if your little patient with difficult IV access is hemodynamically stable and amenable to a bolus over an hour, you may choose to start with hypodermoclysis and reevaluate. Predicting Difficult IV Access in Children Much has been studied and written about the predictors of difficult IV access in children. The most often cited are: age < 3 years, weight less than 5 kg, prematurity, obesity, and darker skin tones, where the contrast of vein to skin may not be so apparent. The three main predictors of the score validated by Riker et al. in Annals of Emergency Medicine include the most practical and universal of features: vein palpability, vein visibility, and patient age. If you’re anticipating difficult IV access in the child who can stand to wait an hour for a slow bolus, you may start with the subcutaneous route to get those veins plumper and more visible, to improve your chances of IV access in the very near future. Medications via Subcutaneous Route Certain medications have been used safely via subcutaneous infusion; always check dose, rate, and compatibility.   What about catheter size? You don’t need to use larger needles or angiocathters for older children, adolescents or adults. A 25-gauge butterfly or 24-gauge angiocatheter works well from an infant to an elder. In one study of adults, a half a liter of saline was infused by gravity via a 24-gauge catheter. With IVs, the shorter and larger the bore, the faster the infusion. In subcutaneous infusion, it is not the size of the catheter, but the osmotic gradient that determines the rate of absorption. What if I don't have that fancy hyaluronidase? It’s actually increasingly readily found – and available in generic form. If you have it, please use it – it will make a believer out of you and others. Hypodermoclysis will work without hyaluronidase – the process of subcutaneous rehydration just takes a lot longer to work. In a double-blind cross-over trial Thomas et al. in 2007 compared subcutaneous administration of lactated ringer’s solution by gravity with and without hyalurondase. The hyaluronidase group received their fluids 5 times faster. The average rate of the hyaluronidase group was 382 mL/h versus the fluid only group, who did not receive hyalurinodase; they were substantially slower, at 82 mL/h. It’s worth using if you have it, but still potentially useful if you don’t. Recap: Supplies √    EMLA or any topical anesthetic used for intact skin, placed as soon as the decision is made √    A 25-gauge butterfly needle or 24-gauge angiocatheter √    IV tubing, gauze to pad, tape to anchor √    150 U hyaluronidase, the same dose, regardless of age or size √    Isotonic fluids – you can start with 20 ml/kg √    And finally a well informed team made up by the patient, the parents, and your staff, so that everyone knows what to expect for a successful subcutaneous fluid administration. References Allen CH, Etzwiler LS, Miller MK, Maher G, Mace S, Hostetler MA, Smith SR, Reinhardt N, Hahn B, Harb G; INcreased Flow Utilizing Subcutaneously-Enabled Pediatric Rehydration Study Collaborative Research Group. Recombinant human hyaluronidase-enabled subcutaneous pediatric rehydration. Pediatrics. 2009 Nov;124(5):e858-67. Bruno VG. Hypodermoclysis: a literature review to assist in clinical practice. Einstein (Sao Paulo). 2015 Jan-Mar;13(1):122-8. Cabañero-Martínez MJ, Velasco-Álvarez ML, Ramos-Pichardo JD, Ruiz Miralles ML, Priego Valladares M4, Cabrero-García J. Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study. Palliat Med. 2016 Jun;30(6):549-57. Kuensting LL. Comparing subcutaneous fluid infusion with intravenous fluid infusion in children. J Emerg Nurs. 2013 Jan;39(1):86-91. Mace SE, Harb G, Friend K, Turpin R, Armstrong EP, Lebel F. Cost-effectiveness of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in children with mild to moderate dehydration. Am J Emerg Med. 2013 Jun;31(6):928-34. O'Hanlon S, Sheahan P, McEneaney R. Severe hemorrhage from a hypodermoclysis site. Am J Hosp Palliat Care. 2009 Apr-May;26(2):135-6. Remington R, Hultman T. Hypodermoclysis to treat dehydration: a review of the evidence. J Am Geriatr Soc. 2007 Dec;55(12):2051-5. Riker MW, Kennedy C, Winfrey BS, Yen K, Dowd MD. Validation and refinement of the difficult intravenous access score: a clinical prediction rule for identifying children with difficult intravenous access. Acad Emerg Med. 2011 Nov;18(11):1129-34. Rouhani S, Meloney L, Ahn R, Nelson BD, Burke TF. Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics. 2011 Mar;127(3):e748-57. Smith LS. Hypodermoclysis with older adults. Nursing. 2014 Dec;44(12):66. Spandorfer PR. Subcutaneous rehydration: updating a traditional technique. Pediatr Emerg Care. 2011;27(3):230-6. Thomas JR, Yocum RC, Haller MF, von Gunten CF. Assessing the role of human recombinant hyaluronidase in gravity-driven subcutaneous hydration: the INFUSE-LR study. J Palliat Med. 2007 Dec;10(6):1312-20. Vacha ME et al. The Role of Subcutaneous Ketorolac for Pain Management. Hosp Pharm. 2015 Feb; 50(2): 108–112. Zaloga GP, Pontes-Arruda A, Dardaine-Giraud V, Constans T; Clinimix Subcutaneous Study Group. Safety and Efficacy of Subcutaneous Parenteral Nutrition in Older Patients: A Prospective Randomized Multicenter Clinical Trial. J Parenter Enteral Nutr. 2016 Feb 17. pii: 0148607116629790. [Epub ahead of print]   This post and podcast are dedicated to Christina L. Shenvi, MD, PhD, for her dedication to excellence in patient care and enthusiasm in #FOAMed, Emergency Medicine, and Geriatric Emergency Medicine.  There are many shared lessons learned in the care of children, elders, and families.  Thank you. Catch Dr Shenvi on the innovative GEMcast. Subcutaneous Infusion Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

PEM Currents returns with a look at topical anesthetics used in the Emergency Department. Specifically this edition of the podcast will focus on LET, EMLA and LMX and discuss typical use.