In contrast to the studies in adults, Babl and colleagues, in a well-designed comparison of nebulized 2% lidocaine at 4 mg/kg to saline placebo in children between 1 to 5 years of ag e in the ED, found distress scores were very high in both groups during NG tube insertion a nd terminated the study early (Babl et al., 2009 ). No child demonstrated any evidence of l idocaine toxicity but, of note, the trachea was inadvertently intubated in one child in eac h group, emphasizing the need for confi rmation of gastric placement by pH, radiograph, or other means (Kuo et al., 2010 ). Further investiga- tions in children are needed to determi ne how best to reduce the pain of NG tube insertion. Perhaps as important, clinicians may r econsider whether NG tube insertion can be avoided (Witting, 2007 ). In older infants and toddlers, behavioral pain scores were high and did not diff er during UC in children less than 2 years of age when 1 to 2 ml of either non-anesthetic or 2% lidoc aine gel was applied topically to the genital mucosa for 2 to 3 min before cath- eterizatio n and the remainder of the gel used as lubricant on the catheter (Vaughan et al., 2005 ). H owever, others found reduced distress when 2% lidocaine gel was applied topically for 2 min then instilled into the urethra for 2 more minutes when compared to non-anesthetic gel in febrile 2- to 24-month-old ED patients (Mularoni et al., 2009 ). When considering the available evidence, it is recommended cli- nicians administer intranas al 2% lidocaine at 4 mg/kg (0.2 ml/kg of 2%) as a gel or atomized spray to children at leas t 5 min prior to NG tube insertion. Oxymetazoline or phenylephrine nasal sprays may be co-a dministered to shrink the nasal mucosa and reduce epistaxis. Most children will show signs of distress during the administration of the lidocaine and NG tube insertion but it is like ly a signifi cant portion of the pain of the procedure will have been abated. Blunting of p rotective airway refl exes may occur with these techniques. In children between 4 and 11 years of age, use of 2% lidocaine gel was associated with sign ifi cantly less pain and distress during UC for cystograms compared to non-anesthetic gel w hen the lidocaine gel was applied with suffi cient time to provide anesthesia (Gerard et al ., 2003 ). A cotton ball soaked with either lidocaine or placebo lubricant was placed on th e urethral meatus and held in place for 1 to 2 min. Th en, dependent upon the size of the c hild, 0.5 to 2.0 ml lubricant or lidocaine gel was instilled into the urethra. Th e instill - lation was repeated twice more, with 2 min intervals between each instillation. A child l ife specialist provided distraction and sup- port during the procedure and rated the child \200\231s distress. Th e group receiving 2% lidocaine gel had signifi cantly lower self-rep ort pain and observed distress. Abdominal pain Abdominal pain is a common nonspecifi c complaint in children seeking medica l evaluation in the ED (Reynolds and Jaff e, 1992 ; Scholer et al., 1996 ). Acute cramping abdominal pain from self- limited minor illnesses such as gastroenteritis or viral infectio ns is not eff ectively reduced by analgesic medications and may be pro- longed by opioids t hat exacerbate intestinal ileus. Many systemic ill- nesses may cause abdominal pain, includ ing diabetic ketoacidosis, haemolytic uremic syndrome, Henoch \200\223Sch nlein purpura, hepati- tis, and myocarditis, the diagnosis of which are usually made with a careful histo ry and physical exam, and, occasionally, specifi c ancil- lary tests. Some causes of abdomi nal pain may require antibiotic treatment including lower lobe pneumonias, urinary tract in fec- tions, streptococcal pharyngitis, and pelvic infl ammatory disease. It is also importa nt to evaluate for conditions that may require urgent surgical intervention such as trauma, volvulus, intussusception, ovarian torsion, incarcerated hernia, or appendicitis. For many of these conditions, administration of an analgesic medication aft er a diagnosis or furth er evaluation or therapeutic intervention is begun will provide some patient relief without obscuring the diagnosis or increasing management errors (Ranji et al., 2006 ). Th e best s tudied example is when the diagnosis of appendicitis is being considered, administration of morphine or buccal oxycodone has been found not to interfere with clinical diagnosis while reducing pain preop- eratively and facilitates diagnostic techniques such as abdominal ult rasound (Sharwood and Babl, 2009 ). However, this practice is frequently underutilized (Gol dman et al., 2006 ; Kim et al., 2003 ). Because signifi cant pain and distress occurs with UC despite use of anesthetic gel, altern ative adjuncts have been investigated. Oral sucrose solution (24%) administered 2 min prior to UC reduced pain scores and crying in infants less than but not older than 30 days of ag e (Rogers et al., 2006 ). Midazolam 0.6 mg/kg orally induced complete amnesia for UC in 60% and partial amnesia in 31% of very anxious children (mean age 4.4 years; Elder and Longene cker, 1995 ) and intranasal midazolam 0.2 mg/kg signifi cantly reduced distress in children median age 2 to 3 years (Stokland, 2003 ). Intranasal fentanyl, 2 mcg/kg, of note, did not reduce UC pain in children 4 to 8 years of age (Chung et al., 2010 ). Most successfully, N 2 O 50% to 70% has been found to reduce distress behavior and need for restraint in childr en during UC compared to non-sedated controls or to those receiving oral midazolam (Keidan et al., 2005 ; Zier, 2007 ). Nasogastric intubation Although emergency physicians and nurses acknowledge the marked disc omfort, NG tube insertion is typically performed with- out any form of pain relief other th an a lubricant in children (Juhl et al., 2005 ; Stock et al., 2008 ). Studies in adults des igned to fi nd an eff ective local anesthetic technique for NG tube insertion have pri- mar ily focused upon use of 2% to 10% lidocaine as a gel, nasal spray, or nebulized mist (Galla gher, 2004 ; Kuo et al., 2010 ). Cetacaine and cocaine have also been investigated but are not recommended due to associated toxicities (US Food and Drug Administration, 2011). A sys tematic review of fi ve randomized controlled trials in adults concluded that administratio n of nebulized or atomized lidocaine before NG tube insertion can decrease pain by 60% (Kuo et al., 2010 ). Two more recent randomized controlled trials in adults like- wise found be nefi t from lidocaine spray (Chan and Lau, 2010 ) and gel (Uri et al., 2011 ). Headache Headache is a common chief complaint in children presenting to the ED (Burton et a l., 1997 ; Kan et al., 2000 ; Lewis and Qureshi, 2000 ). Th e majority of these children ar e diagnosed with viral ill- nesses or migraine headaches. Aft er viral infections, rebound headaches from chronic daily use of ibuprofen or acetaminophen (Vasconcellos et al., 1998 ) , and rare but life-threatening causes of headache, including meningitis, encephalitis, int racranial abscess CHAPTER 34 effective management of children \200\231s pain 343 or hemorrhage, hydrocephalus, hypertension, or brain tumor are excluded by a careful histor y, neurological exam, and, if necessary, intracranial imaging (Kan et al., 2000 ; King, 201 2 ), the diagnosis of migraine headache should be considered (Lewis, 2009 ). Migraine heada ches in children are defi ned as recurrent headaches with pain- free intervals and at least three of the following six symptoms: (1) an aura; (2) unilateral location; (3) throbbing o r pulsatile pain; (4) nausea, vomiting, or abdominal pain; (5) relief aft er sleep; and (6) a family history of migraines (Lewis, 2009 ; Prensky and Sommer, 1979 ). Furthermore, unanticipated arrival or deterioration of other criti- cal ED patients may dem and sedating team members \200\231 immediate attention. Th ese possibilities impact ED PSA choices. Goals of ED PSA are the same as for elective PSA, with the fore- most being assurance of th e patient \200\231s safety and welfare during sedation and recovery. Aspects with particula r pertinence to ED PSA include: (1) Most children undergoing ED PSA are ASA Physical Status Class I and II and at low risk for serious adverse events when closely monitored and simple rescue interventions quickly a pplied (Green et al., 200; Pe a and Krauss, 1999 ). However, children with acute illness es may have less cardiopulmonary reserve and more likely to have adverse responses to sedat ive and analgesic medications, but perhaps less so when ketamine is used (Green et al., 200 9 ). A focused physical exam immediately prior to sedation should be repeated to detect any changes in the child \200\231s physiological status such as acute onset of wheezing or fev er which may increase risk for adverse events. Pharmacological treatment of migraine headaches in children in the emergency setting is pri marily based upon trials in adults due to few pediatric studies (Lewis et al., 2004 ). As w ith other painful conditions, the therapeutic goal is reduction in pain, nausea, and other symptoms to a level which the patient can tolerate; complete abolition of symptoms is uncom mon. If the patient has not already taken an eff ective dose prior to ED presentation, an o ral dose of ibu- profen, 10 to 15 mg/kg, or acetaminophen 15 mg/kg may provide relief (Dame n et al., 2005 ; Lewis et al., 2004 ). Triptans, although not formally approved for use in children, have been shown to reduce migraine-related pain in this age group with benefi t b est demon- strated in use of nasal sumatriptan 10 to 20 mg (Damen et al., 2005 ; Eiland, 20 10; Lewis et al., 2004 ). Because triptans induce vasocon- striction, their use with basila r artery and hemiplegic migraine may worsen symptoms. (2) Fasting is a well-established consensus-based practice to reduce aspiration risk during elective general anesthesia. However, little clinical data has been published to help dete rmine risk of adverse events when children undergoing ED PSA have not fasted or whether pos tponing PSA for a short period reduces risk (Green et al., 2007 ; Mace et al., 2008 ). Prot ective airway re \202 exes are gen- erally preserved during moderate sedation (American So ciety of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists, 2 002) and relatively intact during deep sedation or even light general anesthesia with ketam ine, the most commonly used drug for ED PSA in children (Green et al., 2011 ). However, the se re \202 exes are likely blunted during deep sedation with opioids, benzodiazepines, bar biturates, and pro- pofol, especially during periods of apnoea (American Society of Anesthe siologists Task Force on Sedation and Analgesia by Non- Anesthesiologists, 2002; Oberer et al., 2005 ). Intubation of the trachea, rarely performed for ED PSA, likely increases the r isk of pulmonary aspiration due to pharmacological abolition of protective re \202 exes to facilitate intubation and mechanical inter- ference with glottis closure during passage of the endotracheal tube; thus elective intubation for ED PSA may increase risk of aspiration . Routine administration of antacids or pharmacologi- cal agents to increase gastric motili ty prior to general anaesthe- sia is not bene \201 cial (American Society of Anesthesiolog ist Task Force on Preoperative Fasting, 1999); this likely holds true for ED PSA. Th e combination of intravenous hydration, ketorolac, and prochlo- rperazine may be an eff ective treatment for pediatric migraine headaches (Damen et al., 2005 ; Lewis et al., 2004 ). A randomized double-blind trial in 62 children aged 5 to 18 years presenting to the ED w ith a migraine headache compared IV ketorolac (0.5 mg/kg; maximum 30 mg) to prochlorperazin e (0.15 mg/kg; maximum 10 mg), aft er normal saline 10 ml/kg infused over 30 min (Brousseau et al., 2004 ). By 60 min, 55% of those who received ketorolac and 85% of those who receiv ed prochlorperazine had a 50% or greater reduction in pain scores; neither group experience d signifi cant adverse eff ects. Unfortunately, IV preparations of prochlorperazine are in short-supply or unavailable in the US. Alternative antiemet- ics that may be eff ective but little studied include promethazine, chlorpromazine, metoclopramide, and ondansetron. Pediatric procedural sedation and analgesia (PSA) in the ED When eff ective local anesthesi a is not possible for intensely pain- ful ED procedures or when distress-related behaviors will interfere with accomplishment of the procedure, sedation may be necessary. Many advanc es in PSA for non-elective procedures in non-fasted children in the ED have been developed (Kennedy, 2011 ). Th is sec- tion will review aspects especially pertinent to pediatric PSA in the ED (see also Cravero, Chapter 20, this volume). Th e incidence of pulmonary aspiration during ED PSA is not well established but appears to be very low. Pooling of the available data in the literature suggests the incidence of cli nically apparent pulmonary aspiration during ED PSA is no more frequent than 1:2000 pediatr ic patient encounters (Mace et al., 2008 ). PSA in children receiving emergency care has greater inherent risks than elective sedation. Patients frequently have not fasted and thus may have \200\230full stomachs \200\231 (Agr awal et al., 2003 ; Babl et al., 2005 ; Roback et al., 2004 ). More importantly, gastric em ptying unpre- dictably may slow or stop due to ileus caused by painful injury or serious il lness and is delayed further by opioids administered for pain management. Th us, brief post ponement of sedation may have little impact. Compounding this issue, children undergoing pa in- ful or anxiety provoking procedures typically require deeper lev- els of sedation than adults or teenagers to control their behavior. Vomiting, usually during recovery, is a common adverse event during ED PSA in children, occ urring in as much as 25% of patients when opioids are co-administered prior to sedation (Lu hmann et al., 2006 ; Wathen et al., 2000 ). No correlation was found between the length of preprocedural fasting and vomiting in children receiv- ing ketamine or N 2 O (Agrawal et al ., 2003 ; Babl et al., 2005 ; Roback et al., 2004 ). Coadministration of ondansetron reduce d vomit- ing associated with ketamine ED PSA from 12.6% to 4.7% with 13 patients needing to be treated to prevent one episode of vomiting SECTION 4 pain in specific populations and diseases 344 (Langston et al., 2008 ). Fortunately, protective airway refl exes are likely present durin g active vomiting. Passive regurgitation of gastric contents due to relaxed gastro-oesophag eal sphincter tone, e.g. dur- ing apnoea, however, may be associated with pulmonary aspirat ion. When local anesthesia or eff ective analgesia can be achieved, safety may be enhanced and some children may prefer lighter lev- els of sedation without loss of awareness, e.g. N 2 O with a fracture haematoma block. successful use. Guided imagery signifi cantly augments N 2 O \200\231s effi - cacy and help s allay anxiety. Children na ve to intoxication are frequently frightened by the fl oati ng or tingling sensations caused by the gas, but they usually accept these eff ects when in corporated into non-frightening story-telling (Clark and Brunick, 2007b ; Clark et al., 200 6 ). N 2 O can safely be administered by specially trained nurses to healthy children for E D PSA (Frampton et al., 2003 ). N 2 O is eff ective for brief painful ED procedures, especially when local anesthesia is us ed \200\224examples include lacerations, lumbar puncture, IV placement, urethral catheteriz ation, and abscess inci- sion and drainage (Babl et al., 2008b ; Keidan et al., 2003 ; Luhm ann et al., 2001 ). Oxycodone 0.2 mg/kg PO (or fentanyl IN 2 mcg/kg) provides additional an algesia in young children with injuries that are diffi cult to fully locally anesthetize an d may result in deep sedation (Seith et al., 2012 ). In many smaller EDs, the only physician present must be respon- sible for performing both t he sedation and the procedure. In these situations, there must be a second staff member at the bedside who has been trained in sedation and resuscitation techniques. Th is sec- ond p erson is responsible for monitoring the patient \200\231s cardiopul- monary status and the need for interventions to manage adverse events. Th is individual may, for moderate sedatio n, assist with minor, interruptible tasks once the patient \200\231s level of sedation and cardiopulmonary functions have stabilized, provided adequate monitoring of the patient is m aintained (American Academy of Pediatrics Committee on Drugs, 1992 ; American Society of An esthesiologists Task Force on Sedation and Analgesia by Non- Anesthesiologists, 2002 ; Godw in et al., 2005 ). For deep sedation , this second staff member should have no other respon sibilities than monitoring the patient and recording. Th is usually means a third provider is needed if assistance in performing the procedure is expected. Th e responsible physician must be able to easily inter- rupt performance of the procedure to assist with or assume m an- agement of adverse events. For displaced mid to distal forearm fractures, a combination of N 2 O + oxycodone or intran asal fentanyl + lidocaine haematoma block reduces patient distress as eff ectively as ketam ine, avoids need for venous access, and results in rapid recovery (Luhmann et al., 2006 ). An eff ective haematoma block (2.5 mg/kg, maximum 100 mg buff ered 1% lidocaine) is critica l for this technique. For simple greenstick fractures, the haematoma block is less reliable but signifi cant analgesia is provided and residual pain during reduction is oft en amelio rated by partial amnesia (Hennrikus et al., 1995 ). Ketamine induces dissociative deep sedation or light general anesthesia within 60 sec of IV administration with little signifi cant respiratory depression or blunting of protective a irway refl exes and causes a mild increase in heart rate and blood pressure (Green et al., 2011 ). It more eff ectively reduces pain and distress and causes less adverse cardiopulmon ary eff ects than regimens using fentanyl with midazolam or propofol (Godambe et al., 2003 ; Kennedy et al., 1998 ). Because of these attributes, ketamine is the most widely used tec h- nique for ED PSA in children. Nonetheless, respiratory depression or apnoea, usually bri ef, may rarely occur (Green et al., 2009 ). Complete lack of responsiveness to painful stim uli is unnecessary with keta- mine as it is also a potent amnestic agent (Kennedy et al., 1 998 ). ED PSA technique recommendations for children Many PSA techniques for ED pediatric procedur es have been reported (Kennedy, 2011 ). It is recommended that the provider become knowledg eable and experienced with a limited number when initially gaining experience with pediatri c ED PSA. Use of N 2 O or ketamine enables safe and eff ective ED PSA in children for most ED procedures. Techniques that have greater frequency of adverse cardiopulmonary eff ects, e.g. fentanyl + propofol or mida- zolam, should be used only by experienced sedation provid ers. Laryngospasm has been reported to occur in as many as 0.3% of children undergoing ketamine PSA, oft en during recovery (Green et al., 2009 ). Providers must be prepared to manage lar yngospasm by initiating continuous positive airway pressure along with jaw thrust-head tilt to open the airway. Th ese interventions likely will be suffi cient, but if obstruction pe rsists, succinylcholine (0.1 \200\2231 mg/kg IV) may be required to break the laryngospasm (Hampson-Evans et al., 2008 ). Most laryngospasm will be brief but relapses have been repor ted (Cohen and Krauss, 2006 ). Febrile upper respiratory infec- tions may increase risk for laryngospasm (Olsson and Hallen, 1984 ). N 2 O 50% to 70% induces mild to moderate sedation with anxi- olysis, moderate analgesia, a nd partial amnesia. Its advantages include no need for venous access, rapid onset and off s et (within 2 \200\2235 min), and few adverse eff ects other than vomiting or occasional dys phoria. Delivery of the gas via full face mask rather than a den- tal-style nasal hood is m ore eff ective for ED PSA. Deeper sedation can be achieved by co-administration of opioids with N 2 O but the risk of adverse eff ects, especially vomiting, is increased (Luhmann et al., 2006 ; Seith et al., 2012 ). At a specifi c concentration of N 2 O, depth of sedation can vary considerably. Babl found 90% of children receiving 50% to 70% N 2 O were mildly sedated, whereas moderate or deep se dation occurred in 3% receiving 70% N 2 O and in none receiving 50% (Babl et al., 2008 b). When administered along with IN fentanyl or oral oxyco- done, 50% N 2 O induced deep sedati on in 15% to 20% (Luhmann et al., 2006 ; Seith et al., 2012 ). As much as 10% of children m ay be poorly sedated during ED PSA with N 2 O (Babl 2008b , 2008c ; Luhmann et al., 2001 ). Augmentation of N 2 O analgesic eff ects by concurrent use of local anesthesia and/or syst emic analgesia for painful procedures is also crucial (Babl et al., 2008c ). Since chil- dr en are partially aware during N 2 O sedation, strategies to enhance the gas \200\231s anxio lytic, dissociative, and euphoric eff ects are vital to Conclusion Pain assessment and management in the ED is a vital component of care. Sometimes that involves systemic analgesia, sometimes local anesthesia, sometimes distraction, somet imes sedation, but oft en, all of these. Eff ective management of pain and distress improve s patient outcomes by protecting the children psychologically and physiologically, and by e nabling us to perform more accurate examinations and necessary painful therapeutic and diag nostic procedures. Furthermore, it improves health care provider credibil- ity, parental sa tisfaction, and compliance with recommendations. In this evidence-based review, proven tech niques to achieve these CHAPTER 34 effective management of children \200\231s pain 345 References Agrawal , D. , Manzi , S. F. , Gupta , R. , and Krauss , B. ( 2003 ). Preprocedu ral fasting state and adverse events in children undergoing procedural sedation and analges ia in a pediatric emergency department . Ann Emerg Med , 42 (5), 636 \200\223646. goals have been highlighted and areas where further research is needed to develop improved safe and eff ective methods have been identifi ed. Case example Al-Abdullah , T. , Plint A. C. , and Fergusson , D. ( 2007 ). Absorbable versus nonabsorbab le sutures in the management of traumatic lacerations and surgical wounds: a meta-analysis . Pediatr Emerg Care , 23 (5), 339 \200\223344. American Academy of Pediatrics Committee o n Drugs. ( 1992 ). Guidelines for monitoring and management of pediatric patients during an d aft er sedation for diagnostic and therapeutic procedures . Pediatrics , 89 (6 Part 1), 1 110 \200\2231115. A 3-year-old boy sustained a gaping 3 cm laceration to his fore- head when he fell on the p layground. Topical anesthetic LET gel has been applied during triage. He is fearful and res ists your exam. His mother thinks he will not be still during suturing. You consider sedati on with ketamine but wonder whether there are alternatives that will require less time and fewer ED resources. Th e following strategies are suggested. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesi ologists. ( 2002 ). Practice guidelines for sedation and analgesia by non-anesthesiologists . Anesthesiology , 96 (4), 1004 \200\2231017. American Society of Anesthesiologist Task F orce on Preoperative Fasting. ( 1999 ). Practice guidelines for preoperative fasting and th e use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to he althy patients undergoing elective procedures . Anesthesiology , 90 (3), 896 \200\223905. Th is child has been frightened by his injury and is worried that the treating ED staff , s trangers to him, will cause additional pain during repair. Several techniques may help him feel less threat- ened by refocusing his attention away from his injury. First, chat in a r elaxed manner with his parent. One then might play a brief game with younger patients, e.g. off ering a palm-up \200\230give me fi ve \200\231 hand-slap greeting but quickly move th e hand when the child tries to give the slap, causing him to miss. Surprised by a doctor pl aying a familiar game, many children break into a smile, as do their parents. Alternatively , initially asking the child about her shoes, toy, or some object other than their injury, helps many relax by transferring their attention to something familiar and non-frightening. Likewise, when preparing to suture, one may ask the young child to tell about his last bir thday party, color a picture, recite the \200\230ABCs \200\231 or sing a favorite bedtime lullaby. Playing an interactive game on a computer tablet can be an extremely eff ective di straction. Family members can aid in these distraction strategies but may benefi t from spe cifi c guidance. Suturing as the young child sits in his parent \200\231s lap can be very r eassuring. With school-aged or teenage children, a simple joke, e.g. \200\230So, your sist er/brother/girlfriend, etc, had nothing to do with this (injury), right? ! \200\231 may he lp them relax. Getting the child and parent to laugh usually eases their tension. Anand , K. J. , and Scalzo , F. M. ( 2000 ). Can adverse neonatal experiences alter brain d evelopment and subsequent behavior? Biol Neonate , 77 (2), 69 \200\22382. Babl , F. E. , Goldfi nch , C. , Mandrawa , C. , Crellin , D. , O \200\231Sullivan , R. , a nd Donath , S. ( 2009 ). Does nebulized lidocaine reduce the pain and distress of nasogastr ic tube insertion in young children? A randomized, double- blind, placebo-controlled trial . Pediatrics , 123 , 1548 \200\2231555. Babl , F. E. , Mandrawa , C. , O \200\231Sullivan , R. , and Crellin , D. ( 2008 a). Proced ural pain and distress in young children as perceived by medical and nursing staff . Pediat r Anesth , 18 (5), 412 \200\223419. Babl , F. E. , Puspitadewi , A. , Barnett , P. , Oakley , E. , and Spicer , M. ( 2005 ). Pr eprocedural fasting state and adverse events in children receiving nitrous oxide for proced ural sedation and analgesia . Pediatr Emerg Care , 21 (11), 736 \200\223743. Babl , F. E. , Oakley , E. , Puspitadewi , A. , and Sharwood , L. N. ( 2008 c). Limited ana lgesic effi cacy of nitrous oxide for painful procedures in children . Emerg Med J , 25 , 1 1, 717 \200\223721. Babl , F. E. , Oakley , E. , Seaman , C. , Barnett , P. , and Sharwood , L. N. ( 2008 b). H igh-concentration nitrous oxide for procedural sedation in children: adverse events and dep th of sedation . Pediatrics , 121 (3), e528 \200\223532. Bauchner , H. , Vinci , R. , and Waring , C. ( 1989 ). Pediatric procedures: do In addition, eff ective painless local anesthesia is critical. Instill LET gel directly int o the wound and cover for at least 30 min. Application of LET at the time of triage provide s time for absorp- tion and immediately addresses the child \200\231s pain. If time permits , returning several times to the child \200\231s treatment room to re-apply the LET without causing pain helps desensitize the anxious child to one \200\231s presence and to manipula tion of his wound. Because complete anesthesia may not be achieved with LET, especially in non-facial lacerations, augment the local anesthesia by injecting buff ered lidocaine using a short very fi ne needle, e.g. inch 30 gauge. Show the child the syringe without the n eedle, tell him you will put some medicine into his \200\230owie \200\231 (the wound), tha t \200\230it might feel really cold \200\231 and ask him to let you know if you are \200 \230pushing too hard \200\231 as you apply the medicine. Th is helps the child inter- pret the sensation in a non-frightening manner. Avoid alarming language such as, \200\230a litt le stick \200\231, \200\230burning \200\231, or \200\230hurt \200\231. Obscure the syring e and needle by keeping it close to the child \200\231s face making it diffi cult for the c hild to see the needle. Inject slowly through the wound. Finally, consider administering or al oxycodone, 0.2 mg/ kg, to reduce the tenderness of the bruise surrounding the injury; th is oft en also causes children to feel tired and more relaxed. Using these techniques, the need to sedate children for laceration repair can be signifi cantly reduced. parents want to watch? Pediatrics , 84 , 907 \200\223909. Bauchner , H. , Vinci , R. , and May , A. ( 1994 ). Teaching parents how to comfort their c hildren during common medical procedures . Arch Dis Child , 70 , 548 \200\223550. Baxter , A. L. , Welch , J. C. , Burke , B. L. , and Isaacman , D. J. ( 2004 ). Pain, posit ion, and stylet styles infant lumbar puncture practices of pediatric emergency attending ph ysicians . Pediatr Emerg Care , 20 (12), 816 \200\223820. Baxter , A. L. , Ewing , P. , Evans , N. , Manworren , R. , Ware , A. , and Mix , A. ( 2005 ). EMLA application in ED triage increases venipuncture success. Pediatric Academic Societ ies, 2902. Available at: < http://www. abstracts2view.com/pasall >. Baxter , A. L. , Fisher , R. , Burke , B. L. , Goldblatt , S. , Isaacman , D. J. , and Laws on , M. ( 2006 ). Local anesthetic and stylet styles: factors associated with resident lumb ar puncture success . Pediatrics , 117 , 876 \200\223881. Bhargava , R. and Young , K. D. ( 2007 ). Procedural pain management patterns in academic p ediatric emergency departments . Acad Emerg Med , 14 (5), 479 \200\223482. Bonadio , W. ( 1996 ). Safe and eff ective method for application of tetracaine, adrenaline , and cocaine to oral lacerations . Ann Emerg Med , 28 , 396 \200\223398. 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