Painful therapeutic procedures are often necessary during emergency care of children who have already painful and frightening injuries and illnesses. These procedures are distressful for children, their parents, and their health care providers. Furthermore, inadequately relieved, procedure-related pain produces physiologic and psychological reactions that have acute and long-term consequences, 25,132,153,159,163,172 but children continue to receive less pain medication than do adults with similar significant injuries and illnesses, 15,55 and simple, readily available techniques to reduce pain and anxiety during relatively minor but frightening procedures are often not used. 84,119 A 1998 survey suggests that as many as 40% of children with angulated forearm fractures may receive no sedation-analgesia for fracture reductions in general emergency departments in the United States, 87 and a 1993 study found that 95% of lumbar punctures in a pediatric emergency department were performed without local anesthesia. 119 Advantages of safe and effective management of pain and anxiety in the emergency department include facilitation of controlled accomplishment of evaluations and procedures 31,83,153 ; reduction of psychological trauma and its sequelae 31,95,153,163 ; reduction of stress for the health care provider and parents 40 ; improvement of parental acceptance of rendered care; and, possibly, improvement of accurate evaluation of causes of pain. 112 Why, then, are effective anxiolysis, analgesia, and sedation not commonplace in the emergency department? Explanations are complex and include lack of consensus about optimal safe and effective methods, 25,132,153 medications, 25,34,74,87,153 and patient monitoring 35 ; lack of physician familiarity with psychological and local anesthetic techniques and dosing; fear of adverse effects of potent medications, including concern about addiction 87,115,139,164 ; insufficient time and resources to safely carry out sedations 87 ; minimization of children's pain or misinterpretation as anxiety; and belief that children have only short-term memory of pain. 105,159 Over the past decade, increased recognition of the importance and means for provision of safe and effective management of distress during elective painful procedures in fasted children with cancer and other chronic illnesses has occurred. *
*Reference 25,31,40,54,56,60,80,100,105,133,134,155,159 and 163 . Which of these and other advances can safely provide relief during nonelective procedures in nonfasted patients in the emergency department has been the subject of increasing interest. Family and third-party payer desire for definitive management of acute injuries during initial emergency department visits also seems to be increasing. This article reviews some of the methods shown to safely and effectively decrease children's pain and anxiety associated with procedures in the emergency department (Table 1). Because pain and anxiety are frequently indistinguishable, the combination is often referred to as distress.