Pain & Sedation 1

LJ is a 7yo (29kg, 52”) male who fractured his wrist falling off a skateboard. He has no past
medical history and takes no medications. Vital signs are all normal, but imaging shows that
reduction is required to fix his wrist.
S1) Which of the following would be the most appropriate regimen to recommend for
procedural sedation in LJ?

LJ is a 7yo (29kg, 52”) male who fractured his wrist falling off a skateboard. He has no past
medical history and takes no medications. Vital signs are all normal, but imaging shows that
reduction is required to fix his wrist.

S2) The provider decides to use ketamine to sedate LJ. He is concerned about the potential for
emergence phenomenon and asks you to educate the team. Which is the most important pearl
about emergency phenomenon and ketamine?

KP is a 3yo female who fell chasing the family dog around the living room and now has a
laceration on her lower lip. The physician thinks it will only need a single suture and does not
want to put KP through the additional trauma of IV placement or an IM administration of
sedative, however KP will not sit still, and she wants to provide an intranasal agent.
S3) Which of the following agents is NOT recommended for intranasal administration?

KP is a 3yo female who fell chasing the family dog around the living room and now has a
laceration on her lower lip. The physician thinks it will only need a single suture and does not
want to put KP through the additional trauma of IV placement or an IM administration of
sedative, however KP will not sit still, and she wants to provide an intranasal agent.

P1) KP’s mom is concerned that KP will be in a lot of pain after the suture is placed and asks for
a single dose of “something stronger” than acetaminophen or ibuprofen before she takes KP
home as she knows KP has a low pain tolerance. She remembers taking “Tylenol #3”
[acetaminophen with codeine] for a tonsillectomy as a kid and asks if that would be appropriate
for KP. Which of the following is the most appropriate response to KP’s mom?

JT is a 63yo male (73kg) with a history of “heart palpitations” who presents to your ED
complaining of the same. His initial heart rate is 198, with a blood pressure of 72/41. His EKG
shows SVT. He endorses that he has previously received the medication that “makes your heart
stop” and adamantly refuses to ever take it again because he “saw Jesus and [he’s] not ready to
meet the Lord yet.” The team decides to proceed with cardioversion after vagal maneuvers fail.
S4) Which of the following procedural sedation regimens is most appropriate to recommend for
JT’s cardioversion?

JM is a 45yo female (97kg) who presents to your ED complaining of lower back pain. She said
that she lives with 5/10 chronic back pain, but that it’s a 9/10 today and neither acetaminophen
nor oxycodone provided relief.
P2) The provider taking care of JM asks if a muscle relaxant would be beneficial to JM. Which of
the following is the most appropriate response?

JM is a 45yo female (97kg) who presents to your ED complaining of lower back pain. She said
that she lives with 5/10 chronic back pain, but that it’s a 9/10 today and neither acetaminophen
nor oxycodone provided relief.

P3) While JM is open to the idea of oral therapy, she would really like something IV to get a
“jump start” on treating her pain. She reports that they normally give her the “IV form of
ibuprofen” and asks if that can be given again. After reviewing her chart, you see she is
normally given IV ketorolac. Which of the following is the most appropriate recommendation
regarding ketorolac for JM?

P4) Your ED is extremely busy, with an average 5-hour wait when ZT, a 26yo male (61kg) with a
past medical history of sickle cell disease presents reporting 10/10 pain. He says this feels like
his previous episodes of pain crisis. He has taken 2 doses of his home 10mg oxycodone tablets,
but with no relief. The triage nurse asks what the most appropriate course of action is, as she
doesn’t want to “waste a room” since ZT seems fine and is on FaceTime with a friend. Which is
the most appropriate response to the triage nurse?

DL is a 47yo female (82kg) with a history of opioid use disorder for which she has been in
recovery for 10 years. She presents to the ED with a wrist fracture sustained while rollerblading
with her niece. She is in 10/10 pain but does not want to receive any opioids for pain due to her
history of dependence.
P5) You’ve had a lot of success in your ED recently using ketamine for pain. Which of the
following dosing regimens is most appropriate for DL?

P6) DL has heard about some of her friends being addicted to ketamine and is hesitant to try it.
She would prefer another option if there is one. The physician has been reading lately about
using IV lidocaine for pain management and asks if this would be something to consider for DL.
Which of the following is the most appropriate response?