The evaluation and treatment of patients in the emergency department often involve performing procedures that may be painful and/or frightening to the patient. Although older patients may be able to tolerate a certain degree of discomfort once given an understanding of the need for the procedure, pediatric patients, particularly in the preschool age group, may lack the ability to comprehend what is being performed. This may result in a lack of cooperation, fear of healthcare providers, and a sense of being betrayed by parents or other adults.

The emergency physician should make every effort to allay the patient’s fears and minimize any discomfort. Providing a soothing environment and reassuring, honest explanations of procedures can greatly reduce fear, even in younger children. In some patients, however, pharmacologic means may be necessary to provide sedation during a procedure. Anxiolysis, analgesia, and amnesia may all be goals of sedation. The agent, route, and dosing should be carefully chosen to meet the needs of the particular patient, procedure, and estimated time involved. Although some additional time may be taken in sedating and recovering a patient, improved efficiency and quality in performing the procedure can offset the additional time.

Minimal (Light) sedation describes a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Moderate (“Conscious Sedation”) sedation/analgesia describes a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is maintained. Deep sedation/analgesia describes a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation. Cardiovascular function is usually maintained.

Young children and mentally handicapped or psychologically disturbed older children may not be able to comprehend the need for a procedure. Some patients capable of
understanding may still be unwilling to cooperate for lengthy or particularly painful procedures. Even among those patients who can understand and are willing to cooperate, providing adequate analgesia and anxiolysis may still require sedation.

Sedating agents should not be used in patients with altered levels of consciousness or in whom local anesthetics or oral analgesics can provide adequate relief of discomfort.

Any procedure in the emergency department that causes moderate or severe levels of pain or anxiety may be an indication for sedation of the patient. Examples include burn management, wound debridement and repair, fracture/dislocation reduction, incision and drainage, foreign body removal, thoracostomies, and sexual assault examinations.

Nonpharmacologic measures aimed at reducing anxiety and pain perception can be successful in young children and have the benefit of having few side effects. Procedures should be performed away from the normal background sounds and scenes of an emergency department, in an area containing pleasant images familiar to the child. A calm reassuring manner in which the physician explains the procedure in simple language with carefully chosen words can remove much of the fear of the unknown. Children generally have rich imaginations, and this can be used to suggest diversions, fantasies, or illusions that the child can control to reduce negative perceptions during the procedure. The presence of parents or familiar adults is reassuring, particularly to the small child, and should be encouraged even if it increases the anxiety of the healthcare provider in some cases.

There are a variety of types of medications available that provide sedation. Primary sedatives reduce the patient’s perception of stimuli or awareness of surroundings. They may also reduce anxiety, although that feature is not inherent in all sedatives. Primary analgesics reduce the patient’s perception of pain but may secondarily cause sedation.

It is important to select the appropriate agent for the patient and procedure. Pure sedating agents offer no pain relief, so analgesics or anesthetics must still be used for performing painful procedures even though the patient is sedated. If a single agent does not meet the needs for a given situation, combinations of agents may be used. However, side effects may be additive or synergistic in combination as well.