I would pay good money to see a Doc Holiday/David Herd rumble. Just
hearing the duelling accents would be worth it! A few points:
1) Doc, it's super easy to test on yourself buffered v. not buffered. My
personal N of 1 trial found buffering makes a HUGE difference.
2) That said, I think we need to use even more cerebration than usual
extrapolating needle pain data between children and adults. Children are
not little "me"s. In fact, what I've been finding in my Buzzy trials is
not only the large difference between older and younger kids' sensations,
but between subjects of the same age.
2a) age and skin thickness: Ramsook showed that cold spray increased
distress in children younger than 6years, was the same as placebo for 6 -
12, and worked well thereafter. I think part of the issue is that older
people and darker skinned people have a thicker stratum corneum,
insulating against excessive pain from the cold itself. Children
experience thermal burns from heat in 1/4 the time of adults (Feldman et
al) so the cold spray's -20degree Celcius chill may be too much. Sexy or
not, Yoon et al did study IV access pain and found ice to be superior to
cold spray http://www.ncbi.nlm.nih.gov/pubmed/18082782 and the
temperature variant may be why. Ice is warmer.
2b) Different people's nocioceptors just seem to work with different
degrees of efficiency. Some people find the vibration to be too ticklish
on their Abeta fibers, some find ice packs to be too cold with their C's.
Certtainly what we are finding confirms that young children don't have as
much descending inhibitory control as older children and adults, so the
DNIC pain relief of ice or cold may be wasted on most kids younger than
around 4 or so.
2c) Undoubtedly the giggling induced by moving the ice around helped,
which is a great lesson in and of itself.
3) The infraspinatus trick is BRILLIANT! Are you aware if anyone has
Thanks for the cognitive detour and mental imagery of the Holiday/Herd
Amy Baxter MD FAAP FACEP
Director of Emergency Research, Scottish Rite
Pediatric Emergency Medicine Associates
Doc Holiday <[log in to unmask]> writes:
>From: [log in to unmask]
>> Gosh, I thought I was argumentative.
>--> Hey! I can't argue with that... Maybe you are ;-)
>But probably not as much as I am!
>> Sometimes adult data can be applied to children. I believe this one can
>--> I understand. I can't complain about that, having myself said that
>evidence of the benefit of buffer in children would probably not have
>changed my own management (having no issue with pain as things are).
>Still, there IS evidence in children (Fatovich, 1999) and it appears, if
>you read the actual paper, to be somewhat better in quality than the
>evidence for adults, which fills up the rest of the review...
>Now, I am an "adult" EP, so I don't know as much about kids, I guess,
>than do many others on this list, but I think the "other" factors you
>have already hinted at previously are probably of more importance in kids
>and this might explain why the pH difference does not appear to be as
>clinically significant as it might be in adults.
>I don't expect evidence for the ice technique any time soon. It's not a
>very "sexy" topic, nor will it generate income for any pharma company...
>> ...baking soda still available in Australia. Not sure why there would
>be a shortage elsewhere...
>--> Maybe Oz has cornered the market?
>> Nice goal but still prefer rugby to football...
>--> When I was young enough to ignore the risk to earning, I also used to
>play Rugby, not football. I don't watch sport on TV. But that particular
>goal made it to the MAIN national news bulletins here and was so often
>mentioned that, when all my trainees were also talking about it, I
>decided to have a look myself. Did that just before I wrote my previous.
>> Ps How often do you use ice to reduce the pain of injecting an acid
>into skin? How effective do you find it? Buffering seems in clinical
>practice to turn a painful infiltrate into a pain free one.
>--> I have nothing against buffering. I have never done it nor seen it
>being done, so how could I. As for ice, I was shown this by my trainers
>when I was a medical student in RSA in the 80s. In those days there was
>also a spray we used to "freeze" pointing abscesses in the ED and then
>lance them without anaesthetic. There was only one spray in a huge ED, so
>often we were too lazy to go looking for it an simply grabbed ice from
>our drinks fridge! A few years later, I recall taking my own son, as a
>toddler, to have an immunisation. It was the first time I had had the
>chance to take him myself, so, as I was getting his shirt off, I asked
>for an ice cube and was given one. The other thing I did was to ask for
>the injection to be given over his infraspinatus muscle, not the deltoid.
>Although it did require slightly more of a strip-off to get there, to me
>it was a "no brainer", as it's skin with fewer nociceptors than that over
>the deltoid and the muscle itself would be less "disabling" during the
>1-2 days it hurt, especially for a young child who has to lift his arm up
>to adults all the time...
>The suprspinatus site, unlike the deltoid, is also INVISIBLE to the
>I held the ice cube over the relevant area and moved it around a bit. My
>son started squirming and giggling, as would most kids when tickled. The
>nurse got ready, then I quickly put the needle in and gave the bolus as I
>was moving the ice right by the injection site. I did not stop moving the
>ice over the area until a few seconds after the needle had gone. My son
>did not stop giggling thoughout the whole period. I am 100% convinced he
>did not even realise he had had an injection!
>That same year, having sustained a minor 3-4 cm laceration of my scalp
>while scuba-diving, I had a nurse colleague suture it for me at the dive
>shop - they did have sutures there, but, as you'd expect, no anaesthetic.
>Of course, they did have a fridge for drinks, which had ice in it, as any
>dive shop would...
>Now... All this talk about ice on a Friday afternoon has made me think of
>getting a drink...
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