Keeping Kids Calm without Ketamine

Mitigation of Anxiety and Pain in the pediatric patient is clearly an important aspect of our roles in the ED. It is very challenging to navigate and we often need a roadMAP (see what I did there?)! Unquestionably that roadMAP has destinations that include intranasal medications and Ketamine and Dexmedetomidine; however, the success of any journey that we take with children is often predicated upon whether the patient trusts you. Some people find working with children to be too challenging because children “cannot be reasoned with.” While that is an understandable sentiment, let us not forget that many of our adult patient are also “unreasonable” (on a variety of levels). More importantly, it is often our actions that interfere with the child trusting you. Annals of EM published “Managing the Frightened Child” [Krauss, 2018] which includes some excellent videos of simple strategies that we can utilize to get started off on the correct foot when evaluating children in the ED. In addition, I have the great fortune of working with gifted and brilliant Child Life practitioners. Recently, one of our Child Life Specialists, Caitlin, gave me some additional insights that I wanted to pass on to everyone. So let’s take a moment to consider simple strategies to mitigate anxiety and pain while Keeping Kids Calm without Ketamine:

Keeping Kids Calm: Things to Consider

Observation is your greatest tool! [Krauss, 2018]
  • Sure, Developmental Milestones are critical to comprehend, but… children are not aliens…
  • Just like with any person, eye contact, facial expression, body posture, and gestures will let you assess their level of engagement and level of fear.
One sized approach does not fit everyone. [Krauss, 2018]
  • Some kids will be highly engaged and have little fear: you can address directly without developing apprehension.
  • Children who are not engaged may require you to use strategies to engage them so that they feel at ease with you.
    • Here is where you can play… literally… based on child’s age.
    • Trust can be established by creating a bond through engagement.
    • Appeal to the young child’s curiosity… and the teenager’s self-interests.
  • Children who are noted to be more fearful will require you to “desensitize” them to you and your plans.
    • Speak softly.
    • May need to primarily speak with parents as you slowly demonstrate to the patient that you are “acceptable” to the family (yes… winning parents over is always a good strategy).
    • Slowly move from the boundary where the child appears to be comfortable with you to closer regions.
    • Mirror their posture and positions… don’t stand across room with arms crossed.
    • Do not jump directly to the area of concern.
    • Appeal to their curiosity as you show them your tools, etc.
Slow is Fast
  • Sure, we may be working in a chaotic space at a frenetic pace, but rushing in, moving quickly, and being abrupt is not often well received by children (honestly, adults don’t like it either).
  • Taking a few extra moments to desensitize a fearful child may make it so that the remaining journey does not require Ketamine… which, in the end, makes their disposition and care easier for you!!

Keeping Kids Calm: Things to Avoid!

When asked about common “pitfalls” that providers often fall into when evaluating children, Caitlin (Superior Child Life Specialist) conveyed a few things for us all to attempt to avoid.

Words Matter!
  • Choose your words wisely.
  • Try to avoid saying words like “needle” or “shot” or “IV;” instead say “poke” or “straw.”
  • Try avoid saying phrases like “sew you up” or “put you to sleep;” instead use “string band-aids” or “use sleepy medicine.”
They are listening!
  • This is a good thing. Use it.
    • Talk directly to the children (not just the parents).
    • Describe what you are doing always… being careful about what words you use.
    • “I’m going to touch your belly now” or “I’m going to use my fancy flashlight to look in your ears now.” Avoid surprises!!
    • Explain what they may experience using their senses – ex, “this will feel cold,” “this will sound loud.”
  • Be mindful what words you use when speaking with the parents while the child can hear you (words matter!).
Engage their curiosity!
  • Demonstrate what your going to do on a child’s stuffed animal (push their tummy, look in their ears) 
  • Give the child your tools to manipulate with while your speaking to parents (ie: syringe with water, gauze, tongue depressor, q-tip, etc). This saves time and allows the child to explore the tool so that it is not the tool that is “scary.”
Positioning Matters!
  • Get on the child’s level when able (this is a great way to squeeze in a little extra leg exercises in case your work schedule has prevented you from doing squats at the gym).
  • Use “position of comfort
    • Examine the child while she/he sits on parent’s lap, having parents lay next to them, etc.
    • See Morsel for tips on Oral Exam
Don’t Give Choices that Do Not Exist. (this is also true with your own children)
  • It is good to empower your patients to help with engagement, but …
  • Do not offer options that you are not willing to do.
    • “Are you ready for your stitches?”
      • This is not really an option that they can say no to. If they say “no,” it forces you into an argument.
      • Instead, the choice can be presented as “Would you like to count the number of string band-aids we use?” or “Would you like to watch or look at the iPad?”
    • “Can I look in your ears?”
      • Again… if they say no… you are forced into an argument.
      • Instead, try “Which ear do you want me to look in first?”
Encourage; do not discount.
  • So, this one is difficult to do… but it is just as important as the others.
  • If a child is crying during your exam / procedure, do not discount their feelings.
    • “No need to cry” or “Be Brave” would seem to be comforting phrases to say, but they can instead discount the child’s feelings.
    • Acknowledge their feelings. After all, we know that it is okay to not feel okay. (Thank’s Caitlin for reminding me of this one!!)

References

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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