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2007 Level II), transmucosal (Mahar et al, 2007 Level III‐1), and inhaled routes (Miner et al, 2007
Level III‐2; Furyk et al, 2009 Level III‐2) provided comparable analgesia to IM or IV morphine, with
a similar side‐effect profile. Oral oxycodone was more effective and produced less itching than
codeine, but early administration at triage was required as having Xrays, rather than
examination or casting, was identified as the most painful period (Charney et al, 2008 Level II).
Although no longer used as an anaesthetic, methoxyflurane is available as a self‐administered
®
‘Penthrox ’ inhaler that dispenses 0.2 to 0.7% methoxyflurane (Medical Developments
International, 2001). Use of the Penthrox® inhaler in children reduced pain associated with
extremity injuries (Babl et al, 2006 Level IV) but did not provide adequate analgesia for
subsequent fracture manipulation (Babl et al, 2007 Level IV). Side effects included hallucinations,
vomiting, confusion and dizziness, and sedation/drowsiness was common (26%) in children
(Babl et al, 2006 Level IV; Buntine et al, 2007).
Closed fracture reduction is a major procedure, which may be performed in emergency
departments with a variety of analgesic techniques (Kennedy et al, 2004). IV regional block with
local anaesthetic was safe and effective in 90% to 98% of cases (Murat et al, 2003 Level I), but
complications may arise with faulty equipment, inappropriate use of local anaesthetic, or
inadequate monitoring and training of staff. Inhalation of N 2O was as effective as IV regional
anaesthesia using lignocaine (Gregory & Sullivan, 1996 Level III‐1) and better than IM analgesia
and sedation with pethidine (meperidine) and promethazine (Evans et al, 1995 Level III‐1),
although N 2O has recently been reported to have limited efficacy as a sole agent for fracture
manipulation (Babl et al, 2008 Level IV). N 2O and a haematoma block with lignocaine produced
similar analgesia but fewer side‐effects and more rapid recovery than IV ketamine and
midazolam (Luhmann et al, 2006 Level III‐1). Ketamine‐midazolam reduced distress during
fracture manipulation and fewer paediatric patients required airway interventions than those
receiving fentanyl‐midazolam and propofol‐fentanyl (Migita et al, 2006 Level I). As there is the
potential for complications and a high incidence of side effects with sedative agents,
particularly when given in combination (Cote et al, 2000; Cote, 2008) or in children with
comorbidities (Morton, 2008), fully monitored general anaesthesia may be more appropriate
than sedation or local anaesthesia in some clinical settings (Murat et al, 2003).
Additional paediatric guidelines for procedural sedation, as opposed to analgesia, have been
produced by the American Academy of Pediatrics (Cote & Wilson, 2006) and the Scottish
Intercollegiate Guidelines Network (Scottish Intercollegiate Guidelines Network, 2004).
CHAPTER 10 Psychological interventions
In addition to pharmacological interventions, the planning of procedures for children in the
emergency department should include age‐appropriate psychological interventions, such as
distraction techniques. Distraction reduced self‐reported pain following needle‐related
procedural pain (Uman et al, 2006 Level I). Age‐appropriate distraction techniques reduced
situational anxiety in older children and lowered parental perception of distress in younger
children undergoing laceration repair (Sinha et al, 2006 Level II).

346 Acute Pain Management: Scientific Evidence