Title: Ouchless Options for Pediatric Procedural Sedation<br/>Author: Joey Scollan<br/><a href='http://umem.org/profiles/resident/416/'>[Click to email author]</a><hr/><p>
        <strong>Nitrous Oxide:</strong> Provides anxiolysis, mild analgesia and sedation</p>
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                Pros-
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                                Efficacious</li>
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                                Quick on and off , no lingering effects once gas is removed</li>
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                                Self-titrating when patient holds their own mask</li>
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                                Large safety profile</li>
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                                No fasting necessary</li>
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                Cons-
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                                MUST know contraindications:
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                                                Any patient with an air filled cavity (pneumothorax, pulmonary bleb, bowel obstruction, intracranial process, etc) because nitrous has the ability to diffuse from the bloodstream into these cavities and cause them to expand</li>
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                                                Pregnancy, since nitrous is known to be teratogenic</li>
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                Side Effects-
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                                Nausea and vomiting are by far the most common</li>
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                                An insignificant amount of hypoxia</li>
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        <strong>Intranasal Options:</strong></p>
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                Midazolam
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                                Dosing- 0.2-0.5 mg/kg</li>
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                                Onset: Almost immediate</li>
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                                Duration:  30-45 minutes</li>
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                Fentanyl
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                                Dosing- 1.5 to 3 mcg/kg</li>
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                                Onset:  almost immediate</li>
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                                Duration: 45 minutes – 1 hour</li>
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                Dexmedetomidine
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                                Often used by anesthesiologists as premedication for deeper sedation, not yet appearing in EM literature</li>
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                Ketamine
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                                Limited published data on appropriate dosing and safety profile, but strong potential for future use</li>
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<fieldset><legend>References</legend>

                <p>
        Lane RE, Schunk JD. Atomized intranasal midazolam use for minor procedures in thepediatric emergency department. Pediatr Emerg Care. 2008 May;24(5):300-3. doi: 10.1097/PEC.0b013e31816ecb6f.</p>
<p>
        National Institute for Health and Clinical Excellence (NICE). Sedation in children and young people. Sedation for diagnostic and therapeutic procedures in children and young people. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Dec. 30 p. (Clinical guideline; no. 112).</p>
<p>
         Zier JL, Liu M. Safety of High-Concentration Nitrous Oxide by Nasal Mask for Pediatric Procedural Sedation. Pediatr Emerg Care 2011; 27: 1107-1112.</p>
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