Despite advances in the past decade that decrease pain and anxiety during visits to the emergency room, children continue to receive less pain medication than adults with similar injuries. And simple techniques to reduce pain and anxiety during minor procedures often are not used. Research also has shown that inadequately relieved pain in children has acute and long-term consequences.
Historically, physicians have been afraid of potent medications' adverse effects, and they weren't trained to use these drugs safely, said Robert M. Kennedy, M.D., associate professor of pediatrics at Washington University School of Medicine in St. Louis and emergency physician at St. Louis Children's Hospital. "But we're making progress. More research has been done, and we now have more psychological and pharmacological techniques that reduce pain in children."
In the December 1999 issue of the journal Pediatric Clinics of North America, Kennedy reviewed many of the methods for reducing children's pain and anxiety during emergency procedures in his article "The Ouchless Emergency Department, Getting Closer: Advances in Decreasing Distress During Painful Procedures in the Emergency Department."
...and parents tooUnexpected stress doesn't allow children and their parents to make much use of coping mechanisms. Nevertheless, Kennedy and Janet D. Luhmann, M.D., instructor in pediatrics, found that age-appropriate preparations for pain and anxiety in emergency rooms might dramatically decrease distress in parents and children. Younger children need simplified language and visual explanations, such as hands-on demonstrations with dolls, whereas older children appreciate more detailed information. Kennedy said assuring patients they will be warned before something might hurt and empowering them to control their pain by using relaxation, distraction or self-hypnosis also can help minimize distress.
Research also has shown that children want parents at their sides during painful procedures, even though they know parents may not be able to help manage the pain. It also alleviates some of the parents' anxiety. "In our emergency department, we believe very strongly in having parents there," Kennedy said. "This is a big change, but we think it's important in reducing children's distress."
Effective local anesthesia greatly reduces anxiety and the need for more sedation, Kennedy said. During the past decade, many emergency departments have begun using topical anesthesia such as tertracaine, lidocaine and epinephrine for children's lacerations. Some anxious children who receive pain relief and psychological interventions in emergency rooms still refuse or are unable to cooperate with procedures. Researchers have established guidelines for administering conscious or deep sedation to these children. These guidelines partially focus on standards for staffing and monitoring of patients.
Minimum staffing standards include someone trained in sedation protocols and pediatric advanced life-support techniques. This person monitors the patient's vital functions, administers medication and manages any complications. Also, Kennedy said it is essential to have a registered nurse skilled in pediatric advanced life support monitor the patient and record data on a sedation record.
Educating ER workersIn the review, he also highlighted analgesics currently used on children in emergency departments. Recent research has demonstrated ways in which nitrous oxide, an odorless, tasteless gas, can be used to decrease pain and anxiety in young children. "It also often makes patients laugh, and you can see the relief on parents' faces when that happens," he said.
"Nitrous oxide greatly helps children in our emergency department."
The review also includes suggested methods for procedures such as computerized tomography scans, laceration repairs, joint relocations and abscess incisions.
Kennedy wants parents to be aware that such procedures can be done with much less pain and stress, but his primary goal is that emergency room personnel learn this information. "My preference is that we educate emergency room workers across the country so that these techniques become commonplace," he said. "Most people don't have another emergency department nearby if their hospital isn't using these techniques."
Kennedy said there's a strong national movement to reduce the pain and anxiety of children during emergency room procedures, and he hopes his article will add to the progress. "A lot of what we need to do is implement what we already know and help people understand the impact of pain on children," he said.
Note: For more information, refer to Kennedy RM, "The Ouchless Emergency Department, Getting Closer: Advances in Decreasing Distress During Painful Procedures in the Emergency Department.," Pediatric Clinics of North America, 46, 1215-1247, December 1999.
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