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  • Untreated, pain in children causes short and long-term consequences, and its monitoring in the emergency department should be considered a “fifth vital sign.”
  • The numbing effect of topical lidocaine and tetracaine preparations can be considered effective when there is visible blanching of surrounding tissue.
  • Buffering intradermal lidocaine with 1:9 concentration of sodium bicarbonate will reduce pain from chemical irritation.
  • When removing packing from an abscess, moisten the edges of the packing with lidocaine, epinephrine, and tetracaine to allow for more painless removal.
  • Oral sucrose on a pacifier can provide pain relief for small infants during painful procedures.
  • Children report the most painful part of fracture management is obtaining radiographs. This can be reduced by early splinting of the fracture site.
  • Behavioral techniques for management of pain include relaxation exercises, deep breathing, distraction, and imagery.


Pain is the most common reason a patient presents for health care. The cost of pain to society is exorbitant, and can impact all aspects of life. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) directs that pain be considered the “fifth vital sign,” and monitored with other vital signs in routine medical care. Recently, the International Association for the Study of Pain (IASP) and the World Health Organization (WHO) posited “the relief of pain should be a human right.” Despite growing recognition of the importance of pain, it is often undertreated for children in emergency department (ED) settings.13


This chapter will review the physiologic and clinical research supporting adequate pain management for emergent procedures. Methods of assessing pain in the ED will be presented, along with supporting literature. Specific pain management options will be grouped by procedure or complaint—venipuncture, laceration repair, lumbar puncture (LP), catheterization, severe fracture, burn pain management, and sickle cell pain crisis—and by specific medications, including sucrose for infant pain. Finally, effective and counterproductive behavioral interventions will be discussed.


Untreated pain in children causes short and long-term consequences. In 1987, Anand et al.4 first demonstrated significant immediate morbidity from untreated pain in neonates undergoing PDA ligation, including bradycardia, increased ventilator time, and intraventricular hemorrhage. Pain in infants can have lasting negative effects on neuronal development, pain threshold and sensitivity, coping strategies, emotionality, and pain perceptions.5


While pain control for all emergency patients is often inadequate, children receive less pain medication than adults for the same emergent complaints.3 The reasons for this “oligoanalgesia” include persistence of myths that children do not experience or remember pain,6 fear of using opioids in younger patients, and difficulty assessing pediatric pain.


Concern for pain even in children too young to talk is not frivolous. The effects of untreated pain impact medical outcomes4 and are remembered even by preverbal children.5 These effects may amplify with age: Adolescents avoid medical treatment,7 16% to 75% of adults surveyed refuse to donate blood,810 and geriatric patients refuse flu shots ...

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