If a painful procedure is absolutely necessary, topical anesthetics should be considered as a prelude to the procedure.

There are several options in topical anesthesia and all have been shown to be safe and effective. Cryotherapeutics (e.g., ice, vapo-coolant spray) have short onset times and short durations, which make these agents ideal for brief procedures.¹⁷

Additionally, commercial creams are an option when needing a longer-acting topical anesthetic. If anticipating a painful procedure, these creams are best administered as early as possible in the patient’s presentation because of these agents the prolonged time to onset.

A newer technique being applied in the emergency department is needle-free (jet) injection. This technique utilizes a gas cartridge under high pressure to provide local anesthesia with lidocaine with similar efficacy to the classical approach of using a needle.¹⁸

Topical anesthetics range in cost and time to onset (Table 1) but have overall been shown to decrease pain, improve procedural success rates and increase cooperation.¹⁹

Local and Regional Anesthesia

Local anesthesia can be applied independently or after the application of topical anesthesia. Classically, local anesthesia is achieved with needle infiltration of a local anesthetic (e.g., lidocaine, bupivacaine, prilocaine, etc.). However, there are certain techniques that can reduce the pain associated with the infiltration of local anesthetic. Stimulating the skin proximal to the site of injection, using a 25-gauge or smaller needle, infiltrating slowly²⁰ and using warmed (room temperature) lidocaine²¹ will improve pain associated with injection of local anesthetics. Additionally, using lidocaine buffered with bicarbonate (9:1 parts) decreases the pH of lidocaine, reducing the burning sensation that local infiltration causes.²² For added convenience, the buffered solution can be made in advance and it may remain ­stable for up to 30 days.²³

Regional anesthesia can be used to block pain and sensation in a specific nerve distribution. This targeted anesthesia is especially useful for painful procedures such as joint dislocations, fractures and lacerations.

Because regional anesthesia often requires a smaller volume of anesthetic, this method has a lower risk for systemic toxicity and causes less tissue distortion. The advent of ultrasound in emergency care has helped greatly with the efficacy of this technique.²⁴

Systemic Analgesia and Anxiolysis

For mild to moderate pain, oral medicines are often sufficient. Acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and even some opiate formulations are available in liquid suspensions for easier administration to children. For more severe pain, intravenous agents may be administered. The intranasal route is a less intrusive route of medication administration in the pediatric population. This method is praised for its efficacy, ease and speed, and has been shown to be an effective route for analgesia (i.e., morphine, fentanyl) (Table 2) as well as anxiolysis (i.e., midazolam, ketamine)²⁵ (Table 3).