Self-administered nitrous oxide for fracture reduction in children in an emergency room setting

Closed reduction of paediatric forearm fractures: nitrous oxide versus general anaesthetic

BACKGROUND

Nitrous oxide with intranasal fentanyl is safe and effective in performing closed reduction of paediatric forearm fractures; however, the difference in outcome when compared to those performed under general anaesthesia (GA) is unclear. We aim to compare the outcomes of closed reduction of paediatric forearm fractures under nitrous oxide versus GA.

METHODS

This retrospective study based on a prospective change in protocol reviewed the medical records and radiographs of patients with forearm fractures who presented to a tertiary paediatric centre, and who subsequently underwent closed reduction under either nitrous or GA. Data on patient demographics, type and site of fracture and the method of casting were collected. The primary outcomes were loss of reduction, the need for repeat intervention and the rate of complications.

RESULTS

There were 301 and 362 patients in the nitrous and GA groups respectively. The overall re-intervention rate was 7.6% in the nitrous group versus 5.0% in the GA group (P = 0.155). There was no significant difference in loss of reduction which involved 9.0% in the nitrous group and 11.3% in the GA group (P = 0.320). There was no significance difference in overall complications. Nausea and vomiting comprised the majority of adverse events.

CONCLUSION

Closed reduction of paediatric forearm fractures performed under nitrous oxide with intranasal fentanyl is safe, effective and achieves comparable re-intervention rates and adverse events to those performed under GA in the operating theatre.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Analgesia for Adult Distal Radius Fracture Manipulation in the Emergency Department: Demand Valve Nitrous Oxide Compared with Intravenous Regional Anaesthesia

Introduction

This study compared demand-valve nitrous oxide (Entonox) with intravenous regional anaesthesia (IVRA) as analgesia in adults with distal radius fractures requiring manipulation and reduction (M&R) in the Emergency Department.

Materials and methods

All adults presenting to the Emergency Department of Changi General Hospital, Singapore between August to December 2000 with closed distal radius fractures requiring M&R were enrolled. Five parameters were measured: pain perception using visual analogue scale (VAS), patient acceptance, procedure time, complication rate and failed manipulation.

Results

Of the 67 patients enrolled, 32 received IVRA and 35 received Entonox. The average VAS was 2.2 cm for the IVRA group and 5.8 cm for the Entonox group (p<0.0001). The average procedure time was 25.6 minutes for the IVRA group and 11.1 minutes for the Entonox group (p<0.0001). Twenty-seven IVRA patients (84.4%) and 24 Entonox patients (68.6%) would agree to the same analgesia given similar circumstances (p=0.159). Four patients who received Entonox (11.4%) experienced minor complications, while no complications were noted in the IVRA group (p=0.115). Two patients who received IVRA (6.3%) and 8 patients who received Entonox (22.9%) required more than a single attempt at M&R (p=0.086).

Conclusion

The use of Entonox, compared to IVRA, was associated with significantly shorter procedure time but significantly higher pain scores, with no significant difference in terms of patient acceptance, complication rate or failed manipulation rate. Entonox is an effective analgesic alternative to IVRA in adult patients requiring M&R for distal radius fractures in the Emergency Department. Its use is ideal in situations where IVRA is unsuitable or contraindicated.

A Prospective Clinical Trial Comparing Self-Administered Nitrous Oxide and Haematoma Block for Analgesia in Reducing Fracture of the Distal Radius in an Emergency Department

Objective

To compare the effectiveness and efficacy of self-administered nitrous oxide and haematoma block in pain relief during close reduction of fractured distal radius in adult patients.

Methods

This was a prospective clinical trial. All adult patients aged 18 years or above with fracture of the distal radius within 24 hours requiring close reduction in the Accident and Emergency Department of Kwong Wah Hospital were included. Patients with known contraindications were excluded. A consecutive series of patients were randomised into the two groups in alternating fashion. Pain perception (VAS score), procedure time, patient acceptance and complications were measured and monitored.

Results

A total of 67 patients (53 females and 14 males) with age ranging from 26 to 94 years were enrolled during the period from April 2008 to December 2008; 33 patients received Entonox and 34 received haematoma block. The average VAS score before reduction was 6.97 cm for the Entonox group and 6.76 cm for the haematoma block group (p=0.61). The average VAS score during reduction was 7.19 cm for the Entonox group and 2.80 cm for the haematoma block group (p<0.0001). For the difference of average VAS scores during and before reduction, there was 0.22 cm increase in the Entonox group and 3.95 cm decrease in the haematoma block group (p<0.0001). The relative change of mean VAS score was 3% increase in the Entonox group and 58% decrease in the haematoma block group (p<0.0001). The average procedure time was 6.29 min for the Entonox group and 6.44 min for the haematoma block group (p=1). In the Entonox group, 64% patients agreed to use the same analgesia method under similar circumstances whereas in the haematoma block group, it was 91% (p=0.009). There were no complications or failed reductions in both groups.

Conclusion

Haematoma block is a safe and effective analgesia in the reduction of fractured distal radius with less pain perception, more patient acceptance and similar procedure time compared with Entonox.

Paediatric fractures in a sub-saharan tertiary care center: a cohort analysis of demographic characteristics, clinical presentation, therapeutic patterns and outcomes

Introduction

Paediatric fractures are often of good prognosis due to auto-correction of insufficient fracture reduction by bone remodeling. In sub-Saharan Africa, traditional healers are renowned for managing fractures and there is a neglect for specialized pediatric fracture care. We aimed to determine the demographic characteristics, clinical presentation, treatment patterns and outcomes of paediatric fractures in a tertiary health care centre in Yaoundé.

Methods

We conducted a prospective cohort study of all consenting consecutive cases of fractures in patients younger than 16 years managed between January 2011 and June 2015 at the University Teaching Hospital, Cameroon. We analysed demographic data, injury characteristics, fracture patterns, treatment details, therapeutic challenges and outcome of treatment at 12 months of follow-up.

Results

We enrolled 147 fractures from 145 children with a mean age of 7 years and male-to-female sex ratio of 2.5:1. The main mechanisms of injury were games (53%) and accidental falls (20.7%). Forearm fractures were the most common fractures (38%). The mainstay of management was non-operative in 130 (88.5%) fractures, with 29.3% manipulations under anesthesia and 17 (11.5%) open reductions with internal fixation. The most surgically reduced fractures were supracondylar humeral fractures. Major difficulties were long therapeutic delay, lack of diligent anaesthesia and the lack of fluoroscopy. The outcome of treatment was favorable in 146 (99.3%) paediatric fractures.

Conclusion

With the growing population of sub-Saharan Africa and the objective of becoming an emergent region, public policies should match the technical realities.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Feasibility of a reduction protocol in the emergency department for diaphyseal forearm fractures in children

INTRODUCTION

Diaphyseal forearm fractures are very common pediatric traumas. At present, distal radius metaphyseal fractures are often successfully treated with closed reduction by emergency physicians. However, the management of diaphyseal fractures remains controversial. The purpose of this study was to analyze the results of diaphyseal forearm fractures in the emergency department (ED) in children.

MATERIALS AND METHODS

In a prospective 2-year-study, all closed diaphyseal forearm fractures in patients under 15, with an angle of >15° and treated by closed reduction in the ED were included. Fractures with overlapping fragments were excluded. Reduction was performed by an emergency physician, with a standardized analgesic protocol (painkillers and nitrous oxide). Clinical tolerance was checked within the first 24hours, and the radiographic stability of reduction was assessed at days 8 and 15. Initial and final follow-up radiographs were analyzed. Elbow and wrist range of motion was assessed at the final follow-up.

RESULTS

Sixty patients (41 boys and 19 girls) were included. Mean age was 5.2 years old (±3). At initial evaluation, the maximum angle was 30° (±11.3). After reduction, the maximum angle was significantly reduced (30° vs. 5°, P<0.001). Mean immobilization in a cast was 11.7 weeks (±2). There were no cast related complications in any of these children. There was no surgery for secondary displacement. Full range of motion was obtained in all patients at the final follow-up.

DISCUSSION

The outcome of conservative treatment of closed diaphyseal forearm fractures, without overlapping fragments was excellent. However, reduction is usually performed in the operating room by orthopedic surgeons under general anesthesia and requires hospitalization, which is very expensive. The results of this study show that high quality care may be obtained in the ED by a trained and experienced team. These results are similar to those for distal metaphyseal fractures, which could extend the indications for reduction in the ED.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Applications of nitrous oxide for procedural sedation in the pediatric population

OBJECTIVE

The objective of this review was to provide a general descriptive account of the physical properties, end-organ effects, therapeutic applications, and delivery techniques of nitrous oxide (N2O) as used in the arena of procedural sedation.

DATA SOURCE

A computerized bibliographic search regarding the applications of nitrous for provision of sedation and analgesia during procedures with an emphasis on the pediatric population was performed.

RESULTS

The end-organ effects of N2O have been well described in the operating room setting. Aside from its effects on the central nervous system of sedation and analgesia, N2O may alter intracerebral dynamics and alter cerebral blood flow and intracranial pressure especially in patients with altered intracranial compliance. Effects on ventilation include a dose-related depression of ventilatory function and control of upper airway patency. These effects are generally limited in the absence of comorbid diseases and potentiated by other sedative and analgesic agents. The more clinically significant respiratory effect of N2O on ventilatory function is a dose-dependent depression of the ventilatory response to hypoxemia. Hemodynamic effects include a mild direct depressant effect on myocardial function, which in the absence of comorbid cardiac disease is generally compensated by stimulation of the sympathetic nervous system. Nitrous oxide may potentially aggravate pulmonary hypertension. Additional physiologic effects on neurologic and hematologic function may result in inactivation of the enzyme, methionine synthetase. Recent concern has also been raised regarding the potential effects of N2O on immune function and its relationship to perioperative surgical site infections. Given differences in the solubility, N2O will diffuse into and significantly expand gas-filled cavities. Chronic exposure of health care works to N2O is also a concern. Although there are limited data in the literature to clearly substantiate concerns regarding the reproductive toxicity of occupational exposure to N2O, appropriate scavenging and use of other techniques are mandatory. Nitrous oxide has been shown to be effective for a variety of minor surgical procedures such as venipuncture, intravenous cannula placement, lumbar puncture, bone marrow aspiration, laceration repair, dental care, and minor dermatologic procedures. It is generally as effective as midazolam, with several studies demonstrating it to be more effective. However, its utility is not as great in severely painful procedures such as fracture reduction. Demonstrated advantages to parenteral sedation include a more rapid onset and a shorter recovery time with the majority of patients preferring it to over other agents or agreeing to its use for subsequent procedures. The literature also suggests increased success rates with simple procedures such as intravenous cannula placement when compared with placebo. In general, life-threatening adverse events have not been reported. Most common adverse effects include dysphoria and vomiting. For more painful procedures, combination with another agent may be used, and in all cases, topical or infiltrative local anesthesia is recommended.

CONCLUSIONS

In general, N2O is a useful adjunct for procedural sedation. Given the variety of procedures performed in the pediatric patient, ongoing research is required to identify the most appropriate and effective use of this agent. This may be particularly relevant when evaluating its use for procedures associated with significant pain. In these scenarios, the combination of N2O with other agents needs to be evaluated. Given the potential for adverse effects, strict adherence to published guidelines regarding procedural sedation and monitoring is suggested.

Use of combined transmucosal fentanyl, nitrous oxide, and hematoma block for fracture reduction in a pediatric emergency department

OBJECTIVE

The objective of this study was to evaluate the use of combined inhaled nitrous oxide (NO), hematoma block (HB), and transmucosal fentanyl (TMF) as sedoanalgesia in the reduction of radioulnar fractures in children in a pediatric emergency department (PED).

METHODS

A retrospective, analytical observational study examining the cases of radioulnar fracture reduction in PED from 2007 to 2009 in children from 4 to 15 years old. The cases were divided into 2 groups: those in which only NO + HB was used and those in which TMF was combined with NO + HB. The pain perceived by the child, the doctor, and the nurse was studied during the procedure with 0- to 10-point scales (10 being severe pain). Satisfaction of the medical professionals, duration of the procedure, and the adverse effects that appeared were also studied.

RESULTS

Eighty-one children were included. Sixty-four children (79%) received NO + TMF + HB, and 17 children (21%) received NO + HB only. The pain perceived by the child during the procedure in the group receiving NO + TMF + HB was 2.5 (95% confidence interval [CI], 1.8-3.1) compared with 3.9 (95% CI, 2.3-5.5) in the NO + HB group (P = 0.035), the pain perceived by the doctor was 2.6 (95% CI, 2-3.2) compared with 4 (95% CI, 1.6-4), and by the nurse was 2.7 (95% CI, 2-3.3) compared with 3.9 (95% CI, 2.3-5.5), respectively. Adverse events appeared in 15.3% of the NO + TMF + HB group and in 40% of the NO + HB group.

CONCLUSIONS

The association of NO + TMF + HB in the reduction of radioulnar fractures in PED improves pain control compared with the NO + HB combination. New studies are required to confirm the benefit and safety of this drug combination.

Reduction of anterior shoulder dislocation in emergency department; is entonox(®) effective?

INTRODUCTION

An appropriate procedural sedation and analgesia (PSA) is crucial to reduce a dislocated shoulder successfully in emergency department. This study compares sedative effect of inhalational Entonox(®) (En) to intra-venous (IV) Midazolam plus Fentanyl (F+M).

METHODS

120 patients with recurrent anterior shoulder dislocation were randomly assigned into two groups. 60 patients (group F+M) received 0.1 mg/kg IV Midazolam plus 3µg/kg IV Fentanyl and 60 patients (group En) received Entonox(®) with self administration face mask on an on-demand basis. Traction/counter-traction method was used to reduce the dislocated shoulder joint in both groups.

RESULTS

48 out of 60 (80%) patients in group F+M and 6 out of 60 (10%) patients in group En had successful reduction (p < 0.0001). The mean pain score reduction was 6.3 ± 1.2 for group F+M and 3 ± 0.9 for group En (p < 0.0001). There was a statistically significant difference in mean patient satisfaction (assessed with Likert score) between two groups (4.45 ± 0.6 for group F+M and 2.3 ± 1 for group En; p < 0.0001). Duration of entire procedure (since the beginning of PSA up to the end of successful or unsuccessful reduction) was shorter in Group F+M, but successful reductions occurred earlier in group En. No major side effect such as airway compromise, retracted respiratory depression, or circulatory failure was occurred in any group.

CONCLUSION

Entonox(®) may not be an appropriate agent to help reducing a dislocated shoulder.

EMLA cream and nitrous oxide to alleviate pain induced by palivizumab (Synagis) intramuscular injections in infants and young children

OBJECTIVE

Palivizumab (Synagis [Abbot Laboratories, Kent, United Kingdom]) is recommended for the prevention of severe lower respiratory tract infections caused by respiratory syncytial virus in infants at high risk. These injections are very painful, and currently the use of analgesics is not systematic. The objective of this study was to compare the efficacy of EMLA with premixed 50% nitrous oxide/oxygen, used alone or combined with EMLA, for pain alleviation during palivizumab injections.

METHODS

This randomized, double-blind, multicenter study included children who were younger than 24 months. Each child randomly received during the first 3 monthly injections 3 different analgesic interventions: (1) EMLA: application of EMLA plus air inhalation; (2) nitrous oxide/oxygen: inhalation of 50/50 nitrous oxide/oxygen plus application of a placebo cream; and (3) nitrous oxide/oxygen plus EMLA: inhalation of 50/50 nitrous oxide/oxygen plus application of EMLA. Each child was his or her own control. Procedural pain was assessed through videotapes with the Modified Behavioral Pain Scale. The procedure itself was subdivided in 2 periods: (1) injection and (2) recovery (first 30 seconds after the removal of the needle). Modified Behavioral Pain Scale scores over time (injection and recovery periods) and among treatments were compared by repeated-measures analysis of variance.

RESULTS

Fifty-five children were included. Mean +/- SD Modified Behavioral Pain Scale pain scores for EMLA, nitrous oxide/oxygen, and nitrous oxide/oxygen plus EMLA were, respectively, 9.3 +/- 1.0, 8.8 +/- 1.2, and 8.2 +/- 1.8 during the injection and 7.8 +/- 1.7, 7.4 +/- 1.9, and 6.9 +/- 2.4 during the recovery period. A significant time and treatment effect in favor of the combined nitrous oxide/oxygen plus EMLA was observed.

CONCLUSIONS

The administration of 50/50 nitrous oxide/oxygen to infants and young children is effective in decreasing the pain associated with palivizumab intramuscular injections. The combined nitrous oxide/oxygen plus EMLA cream was more effective than either EMLA cream or nitrous oxide/oxygen alone.

Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical supervision; careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications; appropriate fasting for elective procedures and a balance between depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure; a focused airway examination for large tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction; a clear understanding of the pharmacokinetic and pharmacodynamic effects of the medications used for sedation, as well as an appreciation for drug interactions; appropriate training and skills in airway management to allow rescue of the patient; age- and size-appropriate equipment for airway management and venous access; appropriate medications and reversal agents; sufficient numbers of people to carry out the procedure and monitor the patient; appropriate physiologic monitoring during and after the procedure; a properly equipped and staffed recovery area; recovery to presedation level of consciousness before discharge from medical supervision; and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children

OBJECTIVES

Ketamine provides effective and relatively safe sedation analgesia for reduction of fractures in children in the emergency department. However, prolonged recovery and adverse effects suggest the opportunity to develop alternative strategies. We compared the efficacy and adverse effects of ketamine/midazolam to those of nitrous oxide/hematoma block for analgesia and anxiolysis during forearm fracture reduction in children.

METHODS

Children 5 to 17 years of age were randomly assigned to receive intravenous ketamine (1 mg/kg)/midazolam (0.1 mg/kg; max: 2.5 mg) or 50% nitrous oxide/50% oxygen and a hematoma block (2.5 mg/kg of 1% buffered lidocaine). All of the children received oral oxycodone 0.2 mg/kg (max: 15 mg) at triage > or = 45 minutes before reduction. Videotapes were obtained before (baseline), during (procedure), and after (recovery) reduction and scored using the Procedure Behavioral Checklist by an observer blinded to study purpose. The primary outcome measure was the mean change in Procedure Behavioral Checklist score from baseline to procedure, with greater change indicating greater procedure distress. Other outcome measures of efficacy included recovery times and visual analog scale scores to assess patient distress, parent report of child distress, and orthopedic surgeon satisfaction with sedation. Adverse effects were assessed during the emergency visit and by telephone 1 day after reduction. Data were analyzed using repeated measures, that is, analysis of variance, chi2, and t tests.

RESULTS

There were 102 children (mean age: 9.0 +/- 3.0 years) who were randomly assigned. There was no difference in age, race, gender, and baseline Procedure Behavioral Checklist scores between ketamine/midazolam (55 subjects) and nitrous oxide/hematoma block (47 subjects). Mean changes in Procedure Behavioral Checklist scores were very small for both groups. The mean change in Procedure Behavioral Checklist was less for nitrous oxide/hematoma block, and patients and parents reported less pain during fracture reduction with nitrous oxide/hematoma block. Recovery times were markedly shorter for nitrous oxide/hematoma block compared with ketamine/midazolam. Orthopedic surgeons were similarly satisfied with the 2 regimens. Of the ketamine/midazolam subjects, 11% had O2 saturations < 94%. Other adverse effects occurred in both groups, but more often in ketamine/midazolam both during the emergency visit and at 1-day follow-up.

CONCLUSIONS

In children who had received oral oxycodone, both nitrous oxide/hematoma block and ketamine/midazolam resulted in minimal increases in distress during forearm fracture reduction at the doses studied. The nitrous oxide/hematoma block regimen had fewer adverse effects and significantly less recovery time.

A double-blind, randomized controlled trial on the use of a 50:50 mixture of nitrous oxide/oxygen in pain relief during suction evacuation for the first trimester pregnancy termination

BACKGROUND

This prospective study assessed the role of a 50:50 mixture of nitrous oxide (N2O) and oxygen for pain relief during the termination of first trimester pregnancies by suction evacuation under conscious sedation.

METHODS

Ninety women undergoing suction evacuation up to 12 weeks of gestation were randomized by a computer-generated randomization list and allocated using sealed envelopes to receive the N2O/O2 mixture or air during the operation. Pain scores during and after suction evacuation, post-operative side effects and satisfaction level were compared.

RESULTS

No statistically significant differences in pain scores, post-operative side effects and satisfaction levels were found between the two groups.

CONCLUSION

N2O/O2 did not reduce the pain level during suction evacuation for the first trimester pregnancy termination under conscious sedation.

Preprocedural fasting state and adverse events in children receiving nitrous oxide for procedural sedation and analgesia

STUDY OBJECTIVE

Established fasting guidelines for analgesia and sedation are difficult to follow in the emergency department (ED), and the association between preprocedural fasting and adverse events has been questioned. We characterize the fasting status of patients receiving procedural sedation and analgesia with nitrous oxide (N2O) in a pediatric ED and assess the relationship between fasting status and adverse events.

METHODS

A prospective case series was conducted in a children's hospital ED over an 8-month period. Patients receiving N2O for procedural sedation and analgesia were enrolled and followed up by telephone call. Preprocedural fasting state and adverse events, as well as N2O concentration, adjunctive drugs, and deepest level of sedation, were recorded. Adverse events were analyzed in relation to fasting status.

RESULTS

Two hundred twenty children who underwent procedural sedation and analgesia with N2O were enrolled. Fasting status was obtained in 218 patients (99.1%). Of these, 155 (71.1%; 95% confidence interval [CI], 64.5%-77.0%) did not meet fasting guidelines for solids There were no serious adverse events and no episodes of aspiration (1-sided 97.5% CI, 0%-1.7%). While in the ED, 46 minor adverse events occurred in 37 patients (16.8%; 95% CI, 12.1%-22.4%). Emesis occurred in 15 patients (7%), including 4 (6.3%; 95% CI, 1.8%-15.5%) of 63 patients who met and in 11 (7.1%; 95% CI, 3.6%-12.3%) of 155 patients who did not meet fasting guidelines for solids. There was no significant difference in median fasting duration between patients with and without emesis.

CONCLUSION

Seventy-one percent of patients undergoing ED procedural sedation and analgesia with N2O did not meet established fasting guidelines. In this series, there was no association between preprocedural fasting and emesis. There were no serious adverse events.

Emergency department management of pain and anxiety related to orthopedic fracture care: a guide to analgesic techniques and procedural sedation in children

Orthopedic fractures and joint dislocations are among the most painful pediatric emergencies. Safe and effective management of fracture-related pain and anxiety in the emergency department reduces patient distress during initial evaluation and often allows definitive management of the fracture. No consensus exists on which pharmacologic regimens for procedural sedation/analgesia are safest and most effective. For some children, control of fracture pain is the primary goal, whereas for others, relief from anxiety is an additionally important objective. Furthermore, strategies for the management of fracture pain may vary by fracture location and patient characteristics; thus, no single regimen is likely to provide the best means of analgesia and anxiolysis for all patients. Effective analgesia can be provided by local or regional anesthesia, such as hematoma, Bier, or nerve blocks. Alternatively, induction of deep sedation with analgesic agents such as ketamine or fentanyl, often combined with sedative-anxiolytic agents such as midazolam, may be used to manage distress associated with fracture reduction. A combination of local anesthesia with moderate sedation, for example nitrous oxide, is another attractive option.

Nitrous Oxide vs Periprostatic Nerve Block With 1% Lidocaine During Transrectal Ultrasound Guided Biopsy of the Prostate: A Prospective, Randomized, Controlled Trial

PURPOSE

We compared the efficacy of Entonox (BOC Gases, Manchester, United Kingdom), a mixture of 50% nitrous oxide and oxygen, with periprostatic infiltration of 1% lidocaine to provide analgesia during transrectal ultrasound (TRUS) guided biopsy of the prostate.

MATERIALS AND METHODS

The study included 235 consecutive men undergoing TRUS guided biopsy of the prostate for elevated prostate specific antigen or abnormal digital rectal examination. Patients were randomized to 3 groups, including group 1-84 controls who did not receive any form of analgesia prior to the procedure, group 2-75 who received periprostatic infiltration with 10 ml 1% lidocaine with biopsies performed 5 minutes after infiltration and group 3-76 who received Entonox for 2 minutes through a breath activated device prior to the procedure and thereafter according to patient preference. All patients were asked to indicate the level of pain experienced before and after the procedure on a 10 cm, nonnumerical, horizontal visual analog score. Results were analyzed using 1-way ANOVA.

RESULTS

Mean patient age was 68.8, 64.9 and 65.2 years, and mean visual analog score was 2.9, 1.6 and 2.2 in groups 1 to 3, respectively. Patients in groups 2 (1% lidocaine infiltration) and 3 (Entonox) experienced significantly less pain during the procedure compared with group 1 controls (p <0.001 and 0.028, respectively). There was no statistical difference in pain scores between groups 2 and 3 (p = 0.08).

CONCLUSIONS

Inhalation of Entonox or periprostatic infiltration with 1% lidocaine can be used for analgesia during TRUS guided biopsy of the prostate since each provides significant and similar pain relief.

Nurse administered relative analgesia using high concentration nitrous oxide to facilitate minor procedures in children in an emergency department

AIMS

To describe the experience of using high concentration nitrous oxide (N(2)O) relative analgesia administered by nursing staff in children undergoing minor procedures in the emergency department (ED) and to demonstrate its safety.

METHOD

Data were collected over a 12 month period for all procedures in the ED performed under nurse administered N(2)O sedation. All children greater than 12 months of age requiring a minor procedure who had no contraindication to the use of N(2)O were considered for sedation by this method. The primary outcome measure was the incidence of a major complication namely respiratory distress or hypoxia during the procedure. Secondary outcome measures were minor complications and the maximum concentration of N(2)O used.

RESULTS

Data were collected for a total of 224 episodes of nurse administered N(2)O sedation over a 12 month period. In 73.2% of children no complications were recorded. One major complication was recorded (respiratory distress) and the most common minor complication was mask intolerance in 17%. The mean maximum concentration of N(2)O used was 60.2%.

CONCLUSIONS

N(2)O is a safe analgesic in children over the age of 1 year undergoing painful or stressful procedures in the ED. It may safely be administered in concentrations of up to 70% by nursing staff after appropriate training.

A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair

STUDY OBJECTIVE

To compare the efficacy and complication profile of oral midazolam therapy and continuous-flow 50% nitrous oxide in alleviating anxiety during laceration repair in children 2 to 6 years old.

METHODS

We conducted a prospective, randomized clinical trial using 4 study groups who required laceration repair: (1) children who received standard care alone, which included comforting and topical anesthesia augmented with injected lidocaine if needed; (2) children who received standard care and oral midazolam; (3) children who received standard care and nitrous oxide; and (4) children who received standard care, oral midazolam, and nitrous oxide. Videotapes were blindly scored using the Observational Scale of Behavioral Distress-Revised (OSBD-R) to assess distress during baseline, wound cleaning, lidocaine injecting, suturing, and recovery. Adverse effects were noted during suturing and by parent questionnaires completed 24 hours after suturing and at suture removal. OSBD-R data were analyzed using repeated-measures analysis of variance. Adverse effect data were analyzed using categorical models.

RESULTS

Two hundred four subjects were enrolled (midazolam plus nitrous oxide 52, midazolam 51, nitrous oxide 51, standard care 50; mean patient age was 4.1 years; 66% were boys). Mean OSBD-R scores were lower for groups that received nitrous oxide during wound cleaning by 2.2 points (95% confidence interval [CI] 1.1 to 3.2), lidocaine injecting by 2.5 points (95% CI 1.4 to 3.5), and suturing by 2.9 (95% CI 1.8 to 3.9). Adverse effects occurred more frequently, and recovery times were longer for groups that received midazolam.

CONCLUSION

For facial suturing in 2- to 6-year-old children, regimens including continuous-flow nitrous oxide were more effective in reducing distress, and had fewer adverse effects and shorter recovery times than midazolam.

Ketamine sedation for the reduction of children's fractures in the emergency department

BACKGROUND

There recently has been a resurgence in the utilization of ketamine, a unique anesthetic, for emergency-department procedures requiring sedation. The purpose of the present study was to examine the safety and efficacy of ketamine for sedation in the treatment of children's fractures in the emergency department.

METHODS

One hundred and fourteen children (average age, 5.3 years; range, twelve months to ten years and ten months) who underwent closed reduction of an isolated fracture or dislocation in the emergency department at a level-I trauma center were prospectively evaluated. Ketamine hydrochloride was administered intravenously (at a dose of two milligrams per kilogram of body weight) in ninety-nine of the patients and intramuscularly (at a dose of four milligrams per kilogram of body weight) in the other fifteen. A board-certified emergency physician skilled in airway management supervised administration of the anesthetic, and the patients were monitored by a registered nurse. Any pain during the reduction was rated by the orthopaedic surgeon treating the patient according to the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS).

RESULTS

The average time from intravenous administration of ketamine to manipulation of the fracture or dislocation was one minute and thirty-six seconds (range, twenty seconds to five minutes), and the average time from intramuscular administration to manipulation was four minutes and forty-two seconds (range, sixty seconds to fifteen minutes). The average score according to the Children's Hospital of Eastern Ontario Pain Scale was 6.4 points (range, 5 to 10 points), reflecting minimal or no pain during fracture reduction. Adequate fracture reduction was obtained in 111 of the children. Ninety-nine percent (sixty-eight) of the sixty-nine parents present during the reduction were pleased with the sedation and would allow it to be used again in a similar situation. Patency of the airway and independent respiration were maintained in all of the patients. Blood pressure and heart rate remained stable. Minor side effects included nausea (thirteen patients), emesis (eight of the thirteen patients with nausea), clumsiness (evident as ataxic movements in ten patients), and dysphoric reaction (one patient). No long-term sequelae were noted, and no patients had hallucinations or nightmares.

CONCLUSIONS

Ketamine reliably, safely, and quickly provided adequate sedation to effectively facilitate the reduction of children's fractures in the emergency department at our institution. Ketamine should only be used in an environment such as the emergency department, where proper one-on-one monitoring is used and board-certified physicians skilled in airway management are directly involved in the care of the patient.

Bedside orthopedic procedures

Orthopedic bedside procedures commonly are performed and are appropriate. As the complexity of patient needs increases and resources are stretched, more patient care, including orthopedic procedures, will be performed in cost-effective but safe environments such as the monitored intensive care setting. Medical technology and expertise are expanding rapidly, and these improved resources can and will allow more procedures to be performed safely and effectively outside the operating room. The decision to perform a specific procedure on a specific patient in a specific environment requires careful consideration of the risk to benefit ratio. This consideration should involve the patient, the physicians, and the entire health care team.

The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department

Painful and frightening injuries and illnesses are frequent reasons for children to seek care in an emergency department. Painful therapeutic procedures are often a necessary part of emergency care and are very distressful for the children, their parents, and healthcare providers. Inadequately relieved pain and distress have acute and long-term consequences, yet methods for pain and anxiety reduction during frightening minor and major procedures are often not used because of lack of detailed knowledge of techniques and fear of adverse effects. This article reviews psychologic and pharmacologic means of safe and effective reduction of anxiety and pain during emergency department procedures.

[Utilization of an equimolar mixture of oxygen-nitrous oxide in a general pediatric ward]

We report our experience of the utilization of the 50% oxygen-nitrous oxide mixture (nitrous oxide 50%) in our general pediatric ward after one year of use.

PATIENTS AND METHODS

Between 1st April 1997 and 31st March 1998, children who had to undergo a painful procedure were proposed to inhale 50% nitrous oxide before the procedure. We evaluate pain, restlessness and adverse effects.

RESULTS

The procedures (127 of them) were carried out in 90 children (61 boys). They were aged from 5 months to 15 years (mean: 5.7 years; median: 4.1 years). Indications were: lumbar puncture (n = 45), burning dressing (n = 29), venous cannulation (n = 12), minor surgery (n = 27), and miscellaneous (n = 14). Inhalation time was between 2 to 70 min (mean: 14.4 min; median: 11 min). Pain was absent or low in 106 cases (83.4%). Restlessness was absent or low in 100 cases (78.8%). Averse events were observed 12 times, but they were always minor and quickly reversible.

CONCLUSION

Nitrous oxide (50%) can be used successfully in a general pediatric ward. Other studies are necessary to define the best conditions.

Anesthesia and analgesia for the ambulatory management of fractures in children

The goal of anesthesia in the ambulatory management of fractures in children is to provide analgesia and relieve anxiety in order to facilitate successful closed treatment of the skeletal injury. Numerous techniques short of general anesthesia are available. These methods include blocks (local, regional, and intravenous), sedation (conscious and deep), and dissociative anesthesia (ketamine sedation). Important factors in choosing a particular technique include ease of administration, efficacy, safety, cost, and patient and parent acceptance. Local and regional techniques, such as hematoma, axillary, and intravenous regional blocks, are particularly effective for upper-extremity fractures. Sedation with inhalation agents, such as nitrous oxide, and parenterally administered narcotic-benzodiazepine combinations, are not region-specific and are suitable for patients over a wide range of ages. Ketamine sedation is an excellent choice for children less than 10 years old. With any technique, proper monitoring and adherence to safety guidelines are essential.

Effectiveness of 50% nitrous oxide/50% oxygen during laceration repair in children

OBJECTIVE

To determine the effect of an inhaled 50% nitrous oxide/50% oxygen mixture on measures of observed anxiety in children during laceration repair.

METHODS

A prospective, randomized, placebo-controlled, double-blind comparison of an inhaled 50% nitrous oxide/50% oxygen mixture (treatment group) with 100% oxygen (control group) during repair of lacerations was performed. The study population was a convenience sample of children aged 2-7 years in an urban pediatric ED. The primary outcome variable was the change in scores before and during laceration repair with a 10-point modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) assessment. The secondary outcome variable was a 4-point anxiety scale measured before and during the procedure.

RESULTS

Thirty patients were entered into the study. Seventeen children inhaled the 50% nitrous oxide/oxygen mixture and 13 inhaled 100% oxygen during laceration repair. There was no statistically significant difference in initial CHEOPS and anxiety scores between the 2 groups (p = 0.687 and 0.809, respectively). The median CHEOPS scores in the treatment group decreased by 5 points, while those of the control patients increased by 3 (p < 0.001). The median anxiety scores in the treatment population decreased by 1 point, with an increase of 1 for the control patients (p < 0.001).

CONCLUSION

Administration of a 50% nitrous oxide/50% oxygen mixture to children during their laceration repair resulted in a significant decrease in measures of anxiety when compared with inhalation of 100% oxygen.

Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation

A prospective, randomized study of intravenous (i.v.) regional anesthesia compared with nitrous oxide gas was performed in a group of 28 pediatric patients with forearm fractures requiring manipulation in the emergency department. The groups were compared in terms of pain perceived by the patients, success of manipulation, safety, and duration of procedure. The methods showed no significant difference in amount of pain perceived by the patient for the total pain experience. No medical complication was seen in either group. Because of a technical problem with an i.v. regional block, fracture manipulation was not completed in one patient. Nitrous oxide treatment required significantly less time for completion of the procedure.

[Sedation and analgesia in children]

This article describes the most current and effective means for providing sedation and analgesia for the pediatric patient. Three basic levels for sedation can be defined: conscious sedation, deep sedation and general anesthesia. Treatment of pain is also established according to an analgesic ladder. Providing safe and effective sedation and analgesia to children requires appropriate selection of drugs and dosage, proper monitoring, knowledge of potential side effects, and adequate airway management equipment and personnel. Agents available for sedation and analgesia of children and therapeutic options according to different clinical situations are described.

Self-administered nitrous oxide and a hematoma block for analgesia in the outpatient reduction of fractures in children

We prospectively studied the efficacy and safety of self-administered nitrous oxide combined with a hematoma block in 100 children who had a closed reduction of a fracture in the emergency department. No child was excluded from the study because of the type of fracture. The average Children's Hospital of Eastern Ontario pain score (CHEOPS), as determined by the emergency-medicine physician who observed the reduction, was 6.8 points (range, 4 to 12 points). The average grade for pain, as recalled by the patient and indicated on a visual-analogue pain scale that ranged from 0 to 10 points, was 6.5 points before the patient received any analgesia and 1.2 points immediately after reduction of the fracture and application of a cast. Ninety-seven patients obtained an analgesic effect from the combination of nitrous oxide and a hematoma block. The three remaining children obtained no effect, and the fracture was reduced with use of general anesthesia. Three additional reductions were technically unsuccessful because of rotational or angular malalignment, and a second reduction was performed with general anesthesia. There were no complications such as vomiting, respiratory depression, a change in the oxygen-saturation level, infection, or nerve injury. We concluded that self-administration of nitrous oxide combined with use of a hematoma block is a safe and effective technique of analgesia for the outpatient reduction of fractures in children.

Intravenous sedation for the closed reduction of fractures in children

The safety and efficacy of intravenous sedation with both a narcotic and a benzodiazepine were evaluated in 104 consecutive children who had closed reduction of a fracture. Six patients had a subsequent additional reduction with intravenous sedation, so the study involved a total of 110 procedures. The average dose of meperidine was 1.47 milligrams per kilogram of body weight, and the average dose of midazolam was 0.11 milligram per kilogram of body weight. The interval between induction of the sedation and performance of the procedure averaged ten minutes, and the total duration of the procedure averaged thirty-nine minutes. There were no episodes of apnea or cardiorespiratory complications. Ninety-six (92 percent) of the initial 104 reductions were successful. Only four patients subsequently needed general anesthesia for a repeat closed reduction. The physician's satisfaction with the method of sedation was good or excellent for 103 (94 per cent) of the 110 procedures. Eighty-one (93 per cent) of eighty-seven patients who were able to respond had no memory of the reduction. A telephone survey conducted after the procedure revealed that eighty-four (98 per cent) of eighty-six parents who responded were satisfied with the method of sedation. Intravenous sedation with a narcotic and a benzodiazepine proved to be a safe and effective method of anesthesia for the closed reduction of fractures in children in our series. Careful monitoring of the patient after sedation is imperative.