Pain management in the emergency department

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Chapter 13 Pain management in the emergency department

John Vinen

Emergency physicians should be competent in the management of pain. The early relief of pain is a right and an expectation when a patient presents to the emergency department. The management of pain is often compromised by misunderstandings, myths, prejudice and inappropriate reliance on inflexible cookbook formulas. Good patient care demands effective pain relief; failure to effectively manage pain is a failure in the quality of care.

Many patients presenting to the emergency department in pain, including those transported by ambulance, remain in pain for prolonged periods after arrival.

Time-to-analgesia (from arrival/triage time) is one of the areas of current focus in the improvement of the quality of care in emergency departments. Studies have demonstrated that delayed and sub-therapeutic pain relief remains a problem, with a median of 58 minutes or more (up to 107 minutes for less urgent triage categories) for time-to-analgesia.

A range of strategies, including nurse-initiated analgesia, have been implemented in order to achieve the time-to-analgesia benchmark of 20 minutes.

Time-to-analgesia will be influenced by many factors, including the patient’s triage category. Patients in severe pain should be allocated triage category 2 (to be seen by a doctor within 10 minutes of arrival) in order to ensure analgesia is administered early. Alternatively, where nurse-initiated analgesia is available, patients in pain may be allocated lower triage categories, unless their condition requires otherwise.

THE APPROACH TO PAIN MANAGEMENT

Acute pain is a symptom, not a diagnosis.

While it is important to treat the pain, the cause should always be identified and treated.

Frequently the cause is obvious, such as acute appendicitis or trauma. Many times, however, the exact underlying aetiology is not clear and a diagnostic work-up is required. A history from the patient or a parent is essential to determine aetiology. The history and examination should cover the following items.

History

• History of present illness (HPI)
• Current medications
• Medication allergies
• Past medical history
• Social history
• Family history

Pain history

• Onset
• Character
• Duration
• Radiation
• Quality
• Ameliorating and provoking factors
• Patient rating, if possible, using a standard pain scoring system (see Figure 13.1)
image

Figure 13.1 Visual analogue scale assessment of pain

Clinical examination

• Observation of response to pain (particularly pre-verbal or cognitively impaired patients), e.g. rubbing a particular area, guarding, facial expression, vital signs (tachycardia, hypertension, tachypnoea).
• Focused physical examination (part of body or region in pain), to include vital signs. Increases in pulse, respiratory rate and blood pressure are often but not always noted in the presence of acute pain. However, vital signs may be normal as a result of other physiologic factors.
• Functional assessment.

Note: Pain medications should not be withheld during initial evaluation for an acute abdomen or any other acute painful condition.

Further diagnostic work-up

Pathology studies, X-rays or other diagnostic tests may be needed, directed by the findings of the history and physical examination.

Specialty consultation

Specialty consultation may be required, particularly for patients with chronic pain syndromes.

ESTABLISHING A PAIN MANAGEMENT PROCESS IN THE EMERGENCY DEPARTMENT

Up to 70% of patients presenting to the emergency department have pain as part of their presenting complaint.

It is important to ensure that there is an efficient and effective process of patient care in the emergency department that includes a sub-process focusing on pain management.

In order to ensure rapid and adequate analgesia for patients presenting with pain, a process of pain assessment and management needs to be in place.

Key components of this process are:

• an alerting/activation process (commonly performed by the triage nurse)
• a uniform method of assessment utilising a standardised pain scoring system

• commonly performed by the triage nurse
• use of a nurse-initiated medication policy can minimise delays in administering analgesia.

The triage process and triage form (electronic and/or hard copy) should incorporate assessment of pain and allocation of a pain score in addition to prescribing and administering analgesia (and other essential medications), with provision for monitoring vital signs including the pain score and response to treatment.

1. Use of a pain pathway or guideline (can be incorporated into a specific condition guideline/pathway)
2. Documentation
3. Ready access to the required equipment and medications
4. Ongoing monitoring of the patient including their response to analgesia (including use of a pain score and, where indicated, a sedation score)
5. Quality of care monitoring using quality indicators such as time-to-analgesia (from time of triage to time of administration)

ASSESSMENT OF PAIN

The assessment of pain with the allocation of a pain score should be considered as one of the seven vital signs.

Accurate assessment of severity and character of the pain and the individual’s response to it is essential in order to decide on the pain management required.

Analgesia is most effective when the patient’s medications are tailored to their requirements.

Different levels of distress from similar degrees of pain stem from variations in a range of factors including culture, ethnicity, environment, beliefs, perceptions of pain, religious beliefs, age, illness, duration of pain and associated symptoms.

Adequate pain assessment begins with the history and physical examination.

There are a range of factors that should be used in assessing the severity of pain and the response to treatment. These include:

• physiological factors

• pulse rate
• blood pressure
• respiratory rate

• behavioural features
• pain scales.

A visual analogue scale (VAS) in centimetres may be used to evaluate the patient’s subjective sensation of pain (Figure 13.1).

Alternatively, a numerical rating scale (NRS) from 0 to 10 (0 = no pain, 10 = worst possible pain, see Table 13.1) has been demonstrated to correlate closely with the VAS in measuring pain, with the VAS and the NRS having almost identical minimum clinically significant differences.

Table 13.1 Suggested analgesia for acute pain in adults based on the VAS or NRS

Pain score Suggested analgesic
1–2 Paracetamol PO ii tabs
3–4 Paracetamol and codeine 8 mg PO ii tabs
5–7
Paracetamol and codeine 30 mg PO ii tabs
or
Tramadol 50–100 mg IVI

8–10 Morphine IVI

Pain response is unique to each individual. A good guide to adequate analgesia is the dozing patient who opens the eyes when his or her name is called.

In the evaluation of acute pain, a difference in the VAS of < 20 mm is unlikely to be clinically significant.

Ongoing monitoring and assessment of pain severity should take place every 2 hours (more frequently where pain is a major feature of the patient’s condition), in addition to requests from the patient for analgesia, and every 8 hours once the pain is controlled.

It is useful to determine the type of pain the patient is experiencing as this can guide the selection of analgesics (more than one type of pain may be present). Pain may be one of three types: somatic, visceral or neuropathic.

1. Somatic pain is well-localised and may be responsive to paracetamol, cold packs, corticosteroids, localised anaesthetic (topical or infiltrate), non-steroidal anti-inflammatory drugs (NSAIDs), opioids and tactile stimulation.
2. Visceral pain is more generalised and is most responsive to opioid treatment.
3. Neuropathic pain may be resistant to opioid therapy and consideration should be given to adjuvant therapy such as tricyclic antidepressants and anticonvulsants.

Table 13.2 Tool for determining type of pain

image

THE RATIONAL USE OF ANALGESICS AND SEDATIVES

A large number of pharmacological agents exist, each with their own indications, contraindications, modes of action and routes of administration. In order to select the correct agent, an understanding of the principles that determine the use of analgesics and sedatives in the emergency department is required.

Always refer to the drug’s product information (PI) before prescribing or administration.

Guiding principles

• Rapid onset of action is required.
• Agents need to be effective, i.e. potent.
• Judicious intravenous administration, either bolus or by an infusion (titration to effect desired), is the most effective way to achieve the desired result.
• Duration of effect is important.
• Concurrent administration of a sedative enhances patient comfort and cooperation.
• A good understanding of the agent’s adverse effects is essential for safe use.
• Resuscitation skills, including airway management, together with a full range of resuscitation equipment, are essential to deal with the occasional situation that occurs as a result of excessive sedation or an allergic reaction.
• Administration of oxygen via mask or nasal cannula with monitoring by oximetry should be considered. (Capnography should also be considered and should be used where there is a risk of hypoventilation leading to hypercapnia.) Patients with known respiratory and cardiovascular disease should be given supplemental oxygen and their oxygen saturation should be monitored; cardiac monitoring may also be necessary.

Pharmacological agents

Simple analgesics

Acetylsalicylic acid (aspirin) with or without codeine, and paracetamol with or without codeine, are commonly used for mild pain. Both are also used as antipyretics; aspirin also has an anti-inflammatory action. Non-steroidal anti-inflammatory drugs (NSAIDs) are also commonly used as analgesics. NSAIDs are more potent analgesics than paracetamol and aspirin. Table 13.3 lists the commonly used agents and their properties.

Table 13.3 Adult sedatives, analgesics and muscle relaxants

image

Narcotics and opioid analgesics

Natural and synthetic opioids are the most commonly use analgesic agents in the emergency department. Opiates should be administered IV and titrated to desired effect. Onset of action is rapid. They may also be administered IM or subcutaneously (SC). Respiratory depression, nausea and vomiting are the most common side effects. Concurrent administration of an anti-emetic (such as metoclopramide) should be considered, except in children under 10 years of age because of the high incidence of extrapyramidal reactions. Supplemental oxygen and oximetry monitoring should be used in patients with cardiac and lung disease. Cardiac monitoring may also be necessary.

Opiates should not be withheld because of a perceived risk of addiction. The dangers of addiction have been exaggerated. Respiratory depression can be reversed by the opioid antagonist naloxone (0.8–2.0 mg IV repeated as necessary). Note: Naloxone has a short half-life compared with narcotic analgesics. Repeat doses may be required.

Morphine should be used in preference to pethidine because:

• Duration of action of pethidine is shorter.
• Pethidine has no additional analgesic benefit.
• Pethidine has a similar side effect profile to morphine including bronchospasm and increased biliary pressure.
• Pethidine is metabolised to norpethidine which is associated with toxic effects, especially seizures, particularly in association with renal dysfunction.
• Pethidine has a range of serious interactions with other drugs.
• Pethidine is the most commonly abused medical narcotic because of its euphoric effects.

In fact, there is very little evidence supporting the continued use of pethidine.

Morphine releases histamine resulting in ‘morphine itch’, a distressing side effect that can be treated with H1 and H2 antagonists.

Tramadol is frequently used as an alternative to morphine and pethidine because it lacks their addictive properties. It can be administered orally, IMI or IVI. Dose reductions are required in patients with impaired hepatic or renal function. Look out for side effects and drug interactions.

Skeletal muscle relaxants

These drugs are used to treat pain due to ligamentous strains, tension myalgias and radiculopathies in combination with rest, splinting and application of heat. Drugs in this group include orphenadrine citrate and benzodiazepines such as diazepam and midazolam.

Nitrous oxide (N2O)

A colourless gas with a sweet taste and odour, this is a good analgesic agent frequently used as a 50% N2O mixture with 50% oxygen (Entonox). It is often used by supervised self-administration. Analgesia occurs within 20 seconds, peaking in 1–2 minutes. It also has potent sedative and anxiolytic properties. It can cause euphoria, dysphoria, drowsiness, light-headedness and nausea.

Contraindications include the presence of gas-containing cavities, especially a pneumothorax.

Nitrous oxide is particularly useful to use with children.

Sedating agents

Benzodiazepines are commonly used in the emergency department, usually in combination with an opioid to treat pain, most commonly during procedures requiring sedation and muscle relaxation (reduction of dislocations and fractures, cardioversion). Hypoventilation, airway obstruction and apnoea can occur with even small doses, particularly in the elderly.

Midazolam has ideal properties for use during procedures requiring short-term sedation because of its short half-life. The dose of midazolam is 0.01–0.15 mg/kg (titrated cautiously to response). Flumazenil, a benzodiazepine antagonist, can be used to reverse the sedative effects of benzodiazepines. It is particularly useful after procedures where midazolam has been used, in order to speed up recovery. The dose is 0.2 mg followed by 0.1 mg increments up to a total of 1 mg: the usual dose is 0.3–0.6 mg. Care should be taken not to produce an acute benzodiazepine withdrawal syndrome. Seizures may occur as a result of its use.

Ketamine

Ketamine is a dissociative anaesthetic. It induces a state of analgesia, amnesia and unresponsiveness to noxious stimuli while at the same time preserving airway and breathing reflexes. With care, it is a safe alternative to general anaesthesia for minor procedures on children in the emergency department. Ketamine should only be administered by staff with advanced airway and resuscitation skills. Patients should be fasting for at least 3 hours and fully monitored during the procedure. For doses and effects, see Table 2.1.

LOCAL ANAESTHESIA

Intravenous regional anaesthesia (Bier’s block)

Intravenous regional anaesthesia is a rapid and effective technique suitable for fracture reduction and extremity wound repair. The technique requires the use of a double blood pressure cuff, drainage of blood from the limb and IV administration of prilocaine (2.5 mg/kg). Prilocaine, because of its high level of tissue binding, is safer to use than lignocaine.

Local infiltration

Lignocaine, with or without adrenaline, is the agent of choice for the majority of local anaesthetic procedures in the emergency department.

Note: Adrenaline should not be used in situations where end arteries are involved, i.e. fingers, toes, nose, ears, penis.

A 0.5–1.0% solution is recommended, and when adrenaline is used it should be used as a 1:200,000 solution. The size of the needle and the speed of injection are important in minimising pain associated with the injection of the local anaesthetic agent. Buffering lignocaine with the addition of sodium bicarbonate (1 mEq/mL per 10 mL lignocaine) decreases the pain associated with lignocaine infiltration. A 25-gauge needle should be used, at least with the initial infiltration, with the rate of injection being as slow as possible. The dose of lignocaine should not exceed 3 mg/kg for plain lignocaine and 7 mg/kg for lignocaine with adrenaline. Adrenaline containing soloutions should not be used for end arteries. Care should be taken to avoid intravascular injection.

Topical application

EMLA patches or cream can be used to anaesthetise small areas in children. They are frequently used in preparation for insertion of an intravenous cannula or lumbar puncture. EMLA is a mixture of 2.5% lignocaine and 2.5% prilocaine. It should not be applied to mucosal surfaces and, where the cream is used, an occlusive dressing should be utilised. The major disadvantage of EMLA in the emergency department is that it takes at least 60 minutes to achieve adequate analgesia.

Topical analgesia using a local anaesthetic agent such as amethacaine (often in combination with a cycloplegic such as homatropine) is commonly used to relieve ophthalmic pain.

Local anaesthetic blocks

A variety of peripheral nerve blocks are possible. Nerve blocks are generally less painful than local infiltration, especially in sensitive areas, including the palm and sole. A useful block is a femoral nerve block which is used for analgesia (usually in combination with a narcotic) for fractured shaft of femur. Either lignocaine or bupivacaine, individually or in combination, is used for femoral nerve blocks.

The dose of lignocaine in the adult is 20 mL 1% with adrenaline (not more than 7 mg/kg).

A combination of 10 mL 1% lignocaine and 10 mL 0.25% bupivacaine with adrenaline (maximum of 2 mg/kg) can be used for rapid onset and long duration of action.

NON-PHARMACOLOGICAL METHODS

Patients presenting to the emergency department in pain focus on the painful stimuli in what is to them an unfamiliar, threatening environment. Establishing a patient–doctor relationship and reassuring the patient at the same time lessens anxiety and fear and can also mitigate the patient’s reaction to pain. The initial encounter with the patient sets the tone for the rest of the patient–doctor interaction; reassurance and empathy go a long way towards managing the situation.

Elevation, the application of ice to the injured area and splinting are effective analgesic techniques, especially for traumatic limb injuries. Using these techniques either singly or in combination can reduce or even obviate the need for pharmacological analgesic agents.

PAEDIATRIC ANALGESIA AND SEDATION

Children have an exaggerated response to painful stimuli. Adequate analgesia and sedation are essential in managing children in what to them is a terrifying environment. Verbal reassurance and parental assistance and distraction are important, though in most situations pharmacological intervention will be required. As with adults, the treating doctor must be adept in advanced airway management and life support.

The assessment of the degree of pain in children can be difficult.

Patients may have pain where communication is difficult or impossible, with physiological or behavioural clues the only indication of the pain. This is usually the case with children where behaviour and physiological responses (pulse rate, respiratory rate and blood pressure) can be useful.

Children as young as 5 years have been shown to be capable of using the visual analogue scale (VAS). Recently the usefulness of a coloured analogue scale (CAS) and a facial affective scale (FAS, see Figure 13.2) were assessed. Both scales have numerical values on the reverse side to assist in documenting the pain severity. Almost all children are easily able to use both the CAS and VAS. A visual analogue scale, facial affective scale or a colour analogue scale should be used in assessing and monitoring pain in children.

image

Figure 13.2 Facial affective scale to assist children in indicating the severity of their pain

Hicks CL, von Baeyer CL, Spafford PA et al. Faces Pain Scale—Revised: toward a common metric in pediatric pain measurement. Pain 2001; 93(2):173–183. Used with permission from IASP®. See http://www.painsourcebook.ca for instructions on use of the scale.

Approach to the child

Non-pharmacological techniques including distraction, reassurance, elevation, application of ice and splinting are just as important, if not more so, in children as in adults. Children lend themselves to alternative routes of analgesic/sedative drug administration: oral, nasal, topical and rectal. The easiest manner of drug administration in children is transmucosally (either orally, nasally or rectally). While the effect of a drug administered this way is less predictable, and higher doses are required compared with parenteral administration, it is a very effective and useful way of administering drugs to apprehensive children (Table 13.4).

Table 13.4 Paediatric sedatives and analgesics

Three main analgesics are routinely used for treating pain in children: paracetamol, ibuprofen and codeine. Paracetamol and ibuprofen are equally effective though paracetamol has fewer side effects. Codeine has variable effectiveness and is less commonly used.

Intranasal (IN) midazolam has been found to be easy to administer, well tolerated, safe and effective for the sedation of children.

No one drug is ideal for all situations—a combination of agents may be required to produce the desired effect. Consideration should be given to using a general anaesthetic in operating theatres if a prolonged or difficult procedure is required.

Neonatal analgesia

The use of oral glucose administered with a dummy has been demonstrated to provide a degree of analgesia in neonates.

Painful injuries or procedures, however, require the careful use of opioids.

ANALGESIA IN THE ELDERLY

Elderly patients are at increased risk of medication-related adverse events, so the risks of administering analgesia must be carefully considered.

Pain relief is a common and important factor in the quality of life of the elderly.

The comorbidity of pain, sleep disturbance and psychological distress is well-recognised in all age groups.

Where possible, because of the associated adverse events, NSAIDs should be avoided in the elderly.

ANALGESIA IN SPECIAL SITUATIONS

There are a number of common clinical situations in the emergency department where a combination of agents or a different approach is required to achieve the desired analgesic and sedative effect (Table 13.5).

Table 13.5 Emergency department approach to analgesia in special situations

Indication Analgesic(s) of choice Adjuncts
Cardioversion
IV fentanyl
IV midazolam

  Renal colic
IV morphine or
IV pethidine
Indomethacin suppositories PR Headache
PO soluble aspirin plus metoclopramide 10 mg IV
Chlorpromazine 12.5–25 mg IV/IM
Sumatriptan 6 mg IM
IV morphine or IV pethidine Fractured shaft of femur
IV morphine or
IV pethidine
Femoral nerve block Ophthalmic pain due to ciliary muscle spasm
Topical tropicamide∗ and/or
IV morphine or
IV pethidine or
Oral analgesics
Cyclopentolate hydrochloride∗
Homatropine hydrobromide

IM, intramuscularly; IV, intravenously; PO, orally; PR, rectally

∗ Contraindication: glaucoma

Analgesia can safely be administered in patients with acute abdominal pain without affecting the physical examination findings.

• Jellyfish stings—hot water (not so hot as to cause burns) is recommended.
• Multiple trauma—a general anaesthetic may need to be administered in order to safely and effectively manage patients with serious injuries.
• Pain due to envenomation—frequently requires the administration of antivenom.

PATIENT MONITORING

Monitoring of the patient’s vital signs (temperature, pulse rate, blood pressure, respiratory rate, level of consciousness, oximetry, pain score) should begin before and continue throughout the recovery phase. The intensity of monitoring will depend on the level of sedation/analgesia, preexisting illness (cardiac or respiratory disease) and the patient’s general condition.

Capnography should also be used where there is a risk of hypercapnia.

PATIENT DISCHARGE

Full recovery from the side effects of analgesia should take place prior to discharge (Box 13.1). Patients, or their parents in the case of children, should be given both verbal and written instructions (Box 13.2).

Box 13.1 Discharge criteria after sedation and analgesia

Return to baseline verbal skills∗

Can understand and follow directions
Can verbalise, including correct diction

Return to baseline muscular control function∗

If an infant, can sit unattended
If a child or adult, can walk unassisted

Return of sensation and muscle function where a nerve block has been used

Return to baseline mental status

Patient or responsible person with the patient can understand emergency department discharge instructions about specific conscious sedation and/or analgesia

∗ These items may need to be modified to account for the patient’s visit to the emergency department

Box 13.2 Paediatric discharge instructions

Your child has been given a sedative or pain medication as part of their emergency department visit today. Medications of this type can cause the child to be sleepy, to be less aware, not to think clearly, or to be more likely to stumble or fall. Because of this they should be watched closely for the next 8 hours. In addition, please observe the following precautions:

• No eating or drinking for the next 2 hours. If your child is an infant, he/she may be fed half a normal feed 1 hour after discharge.
• No play that requires normal childhood coordination, such as bike riding, skating or use of swings or monkey bars for the next 24 hours.
• No playing without adult supervision for the next 8 hours. This is especially important with children who are normally allowed to play outside alone.
• No baths, showers, cooking or using possibly dangerous electrical devices (such as curling irons) without adult supervision for the next 8 hours.
• If you notice anything unusual about your child or have any questions, please call the emergency department immediately.

PEARLS AND PITFALLS

• Delay in administration of analgesia is common. Time-to-analgesia is a quality indicator.
• The presence of pain and the requirement for analgesia should be an integral component of the triage process, with the nurse-initiated medication policy incorporating analgesics.
• Regular assessment of pain results in improved pain management.
• There is good correlation between visual analogue and numerical rating scales.
• Uncontrolled, unresponsive, unusual or unexpected pain requires reassessment of the diagnosis and consideration of alternative causes of the pain.
• Inadequate analgesia is a common problem.
• A combination of non-pharmacological and pharmacological analgesia can be very effective and reduce the dose and frequency of pharmacological agents.
• Side effects of analgesics are common, predictable and manageable.
• The extremes of age require careful attention to and management of the requirements for analgesia.

SUMMARY

Assessment of pain and requirement and administration of analgesia should be integral components of the triage process, coupled with a nurse-initiated medication policy.

An analgesia process should also be built into the overall patient care process of the emergency department, with specific patient care guidelines incorporating pain management.

Time-to-analgesia should be utilised as a continuously monitored emergency department quality indicator.

An understanding of the causes of pain and its effect on patients, together with a detailed history and physical examination, forms the basis of the administration of timely and effective analgesia.

All analgesics have a role in pain management in the emergency department. What is required is a good understanding of the indications, dose, contraindications, side effects and interactions of each analgesic and when to co-administer analgesics in order to achieve maximal effect.

Non-pharmacological strategies should also be utilised where appropriate.

Special attention needs to be given to unresponsive or unusual pain and to the very young and elderly.

DEFINITIONS

Adjuvant analgesic—a drug that has a primary indication other than to treat pain but has analgesic effect in some painful conditions or is capable of decreasing the side effects of analgesics; commonly administered in combination with one of the primary analgesics (e.g. opioids).

Analgesia—absence of pain; commonly used to mean adequate pain relief.

Drug tolerance—this occurs when a fixed dose of a drug produces a decreasing effect so that a dose increase is required to maintain a stable effect; the effect occurs particularly with opioids.

RECOMMENDED READING

American College of Emergency Physicians. Pain management in the emergency department. Online. Available: www.acep.org/practres.aspx?id+29596; 12 June 2008.

American Society of Anesthesiologists website. Available: http://www.asahq.org; 23 June 2008.

Australia and New Zealand College of Anaesthetists (ANZCA) website. Available: http://www.anzca.edu.au; 12 June 2008.

Australian College for Emergency Medicine. Guidelines for implementation of the Australian triage scale in emergency departments. Online. Available: http://www.acem.org.au/oren/documents/triageguide.htm.

Australian Medicines Handbook 2008. Australian Medicines Handbook Pty Ltd, Adelaide, 2008.

Beggs S. Paediatric analgesia. Australian Prescriber. 2008;31:63-65.

Bijur P.E., Sliver W., Gallegher E.J. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med. 2001;8:1153-1157.

Bruckenthal P. Assessment of pain in the elderly patient. Clin Geriatr Med. 2008;24:213-236.

Forero R., Mohsin M., McCarthy S. Prevelance of morphine use and time to initial analgesia in an Australian emergency department. Emerg Med Australia. 2008;20:136-143.

Fry M., Holdgate A. Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia. Emerg Med. 2002;14:249-254.

International Association for the Study of Pain (IASP) website. Available: http://www.iasp-pain.org; 12 June 2008.

Kelly A.M. Setting the benchmark for research in the management of acute pain in emergency department. Emerg Med. 2001;13:57-60.

Little M. First aid for jellyfish stings: do we really know what we are doing? Emerg Med Australia. 2008;20:78-80.

McCleane G. Pain perception in elderly patients. Clin Geriatr Med. 2008;24:203-211.

National Guidelines Clearing House website. Available: http://www.guidelines.gov; 12 June 2008.

National Health and Medical Research Council website. Available: http://www.nhmrc.gov.au/publications; 12 June 2008.

New South Wales Department of Health CIAP website. Available: http://www.health.nsw.gov.au.

Pediatric Emergency Medicine Reports. Pediatric procedural sedation. Part 1, Personnel, monitoring, and patient assessment. Part 2, Selecting an agent. 2007;12:5-6.

Priestly S.J., Taylor J., McAdam C.M., et al. Ketamine sedation for children in the emergency department. Emerg Med. 2001;13:82-90.

Smith H.S. Overview of pain management in older persons. Clin Geriatr Med. 2008;24:185-201.

The Children’s Hospital at Westmead Handbook. McGraw-Hill, Sydney, 2004.

Victorian Medical Postgraduate Foundation. Analgesic guidelines. Melbourne: Victorian Medical Postgraduate Foundation; 1995.

Wang N.E., Vlahos J. Pediatric procedural sedation: personnel, monitiring, and patient assessment. Part 1, Pediatric emergency medicine reports. Part 2, Selecting an Agent. 2007;12:5-6.

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