Lynchburg Journal of Medical Science

Lynchburg Journal of Medical Science


Pediatric Emergency Medicine


Dr. Elyse Watkins



Pediatric patients frequently present to the emergency department with lacerations that need repairing through some interventional process, such as suturing. Young children present added challenges to clinicians that include being frightened, an inability to deal with painful procedures, and difficulty remaining still. As a result, papoose boards were commonly used to physically restrain young children for minor procedures in the emergency department.4 Pediatric emergency room providers make use of multiple modalities to aid in minimizing these challenges. Most providers apply LET (lidocaine, epinephrine, tetracaine) gel to the wound while the patient is waiting for care, to reduce pain when the clinician proceeds with the wound examination.5 The laceration may also need to have lidocaine infiltrated into the wound for supplementary anesthesia before repair. Some departments make use of child life specialists to help with instruction, distraction, and to reduce patient anxiety alone or in conjunction with medications for procedural sedation.6 Some providers in emergency departments use Ketamine for procedural sedation, and others use benzodiazepines such as midazolam alone, or in combination with the previously mentioned modalities to help with anxiolysis.2

Clinicians decide which interventions to use for anxiolysis during emergency department procedures, such as laceration repair, on a case-by-case basis; although they may have personal preferences, they should consider which of the hospital approved methods of administration would provide the patient with the best possible outcome when using midazolam. Clinicians use Midazolam for the induction of anesthesia, the management of acute seizures, and anxiolysis for minor procedures.1 Midazolam administration can be through oral, intranasal, buccal, intravenous, intramuscular, and rectal routes.1 Most often, emergency departments use oral or intranasal midazolam for anxiolysis during minor procedures.2,3 The efficacy of intranasal midazolam for anxiolysis in pediatric patients undergoing laceration repairs compared to oral midazolam depends on multiple factors. This paper describes the current state of the evidence regarding the use of intranasal midazolam in pediatric patients requiring laceration repair.


  1. Lingamchetty T, Saadabadi A. Midazolam. Ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK537321/. Published 2019.
  2. Mellion S, Bourne D, Brou L et al. Evaluating Clinical Effectiveness and Pharmacokinetic Profile of Atomized Intranasal Midazolam in Children Undergoing Laceration Repair. J Emerg Med. 2017;53(3):397-404. doi:10.1016/j.jemermed.2017.05.029
  3. Neuman G, Swed Tobia R, Koren L, Leiba R, Shavit I. Single dose oral midazolam for minor emergency department procedures in children: a retrospective cohort study. J Pain Res. 2018;Volume 11:319-324. doi:10.2147/jpr.s156080
  4. Brown J, Klein E. The “Superhero Cape Burrito”: A Simple and Comfortable Method of Short-term Procedural Restraint. J Emerg Med. 2011;41(1):74-76. doi:10.1016/j.jemermed.2010.11.024
  5. Sherman J, Sheppard P, Hoppa E, Krief W, Avarello J. Let Us Use LET. Pediatr Emerg Care. 2016;32(7):440-443. doi:10.1097/pec.0000000000000276
  6. Hall J, Patel D, Thomas J, Richards C, Rogers P, Pruitt C. Certified Child Life Specialists Lessen Emotional Distress of Children Undergoing Laceration Repair in the Emergency Department. Pediatr Emerg Care. 2018:1. doi:10.1097/pec.0000000000001559


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