Alternatives to sedation for painful procedures.

Pediatr Emerg Care 25(6):415-9; quiz 420-2 (2009) PMID 19528768

Conscious sedation is used frequently to perform procedures that may be undertaken with or without minimal sedation. Fracture manipulation can be performed with minimal discomfort in the awake patient using various techniques-for example, intravenous regional anesthesia, nerve blocks, and hematoma blocks. These have been used for many years and are very safe. They may require some specific equipment (eg, automatic tourniquet) to perform the anesthesia but patients have the same results and are able to go home much quicker because sedation is not used.Use of topical anesthesia for both intact skin and wounds has been used over many years. Its use now should be standard. Nerve blocks can also be used to anesthetize specific areas which may be difficult to use topical anesthesia (eg, lip, hand, etc) or are painful because of injection directly into the wound. These may include infraorbital nerve blocks for lip lacerations, ulna or median nerve blocks for hand injuries, and so on. Other novel approaches to topical anesthesia have seen the use of iontophoresis (again requires specific expensive equipment), jet injection of lidocaine, or "freeze sprays." Each has its own advantages and disadvantages.Femoral nerve block is a useful intervention for analgesia in patients with femoral fractures and can obviate the need for parenteral analgesia and allows excellent analgesia particularly during x-ray examination.Thus, it is important to remember that there are alternatives to conscious sedation which gives good analgesia during the procedure and allows the patient to be discharged sooner.