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Objectives: Nitrous oxide (N 2 O) is an inhaled analgesic/ anxiolytic gas with evidence supporting its safety and efficacy for distressing procedures in children. Despite this, its use is not consistent across Canadian pediatric emergency departments (EDs). We aimed to characterize a) physicians' knowledge and practices with N 2 O and b) site-specific N 2 O protocols in Canadian pediatric EDs to help optimize its use nationally., Methods: This cross-sectional survey was distributed to physician members of Pediatric Emergency Research Canada (PERC) in early 2021. Survey items addressed practice patterns, clinician comfort, and perceived barriers/ facilitators to use. Further, a representative from each ED completed a site-specific inventory of N 2 O policies and procedures., Results: N 2 O was available in 40.0% of 15 pediatric EDs, with 83.3% of these sites having written policies in place. Of 230 distributed surveys, 67.8% were completed with mean (SD) attending experience of 14.7 (8.6) years and 70.1% having pediatric emergency subspecialty training. Of the 156 respondents, 48.7% used N 2 O in their clinical practice. The most common indications for use were digit fracture/ dislocation reduction (69.7%), wound closure (60.5%), and incision & drainage (59.2%). Commonly perceived facilitators were N 2 O equipment availability (73.0% of 156) and previous clinical experience (71.7% of 156). Of the 51.3% of physicians who reported not using N 2 O, 93.7% did not have availability at their site; importantly, the majority indicated a desire to acquire access. They identified concerns about ventilation/ scavenging systems (71.2% of 80) and unfamiliarity with equipment (52.5% of 80) as the most common barriers to use., Conclusions: Despite evidence to support its use, only half of Canadian pediatric ED physicians surveyed use N 2 O in their clinical practice for treating procedure-related pain and distress. Increased availability of N 2 O equipment, protocols, and training may improve clinicians' abilities to better manage pediatric acute pain and distress in the ED., (© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Objectives: The objective of this study was to synthesize indication-based evidence for N 2 O for distress and pain in children., Study Design: We included trials of N 2 O in participants 0-21 years, reporting distress or pain for emergency department procedures. The primary outcome was procedural distress. Where meta-analysis was not possible, we used Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," or "unfavorable" (p < 0.05, supporting N 2 O or comparator, respectively). We used the Cochrane Collaboration's Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate risk of bias and quality of evidence, respectively., Results: We included 30 trials. For pain using the Visual Analog Scale (0-100 mm) during IV insertion, 70% N 2 O (delta:-16.5; 95%CI:-28.6 to -4.4; p = 0.008; three trials; I 2  = 0%) and 50% N 2 O plus eutectic mixture of local anesthetics (EMLA) (delta:-1.2; 95%CI:-2.1 to -0.3; p = 0.007; two trials; I 2  = 43%) were superior to EMLA. 50% N 2 O was not superior to EMLA (delta:-0.4; 95%CI:-1.2 to 0.3; p = 0.26; two trials; I 2  = 15%). For distress and pain during laceration repair, N 2 O was "favorable" versus each of SC lidocaine, oxygen, and oral midazolam but "neutral" versus IV ketamine (five trials). For distress and pain during fracture reduction (three trials), N 2 O was "neutral" versus each of IM meperidine plus promethazine, regional anesthesia, and IV ketamine plus midazolam. For distress and pain during lumbar puncture (one trial), N 2 O was "favorable" versus oxygen. For distress and pain during urethral catheterization (one trial), N 2 O was "neutral" versus oral midazolam. For pain during intramuscular injection (one trial), N 2 O plus EMLA was "favorable" versus N 2 O and EMLA alone. Common adverse effects of N 2 O included nausea (4.4%), agitation (3.7%), and vomiting (3.6%) AEs were less frequent with N 2 O alone (278/1147 (24.2%)) versus N 2 O plus midazolam (48/52 (92.3%)) and N 2 O plus fentanyl (123/201 (61.2%))., Conclusions: There is sufficient evidence to recommend N 2 O plus topical anesthetic for IV insertion and laceration repair. Adverse effects are greater when combined with other sedating agents., (© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: The objective of this study was to explore Canadian emergency physicians' experiences, concerns, and perspectives during the first wave of the coronavirus disease (COVID-19) pandemic., Methods: This cross-sectional survey of physician members of Pediatric Emergency Research Canada and the Canadian Association of Emergency Physicians explored: personal safety/responsibility to care; patient interactions; ethical issues in pandemic care; institutional dynamics and communication practices. Data analysis was descriptive: categorical data were summarised with frequency distributions, continuous data [100 mm visual analog scales (VAS)] were analysed using measures of central tendency. Short open-ended items were coded to identify frequencies of responses., Results: From June 29 to July 29, 2020, 187 respondents (13% response rate) completed the survey: 39% were from Ontario and 20% from Quebec, trained in general (50%) or pediatric (37%) emergency medicine. Respondents reported a high moral obligation to care for patients (97/100, IQR: 85-100, on 100 mm VAS). Fear of contracting COVID-19 changed how 82% of respondents reported interacting with patients, while 97% reported PPE negatively impacted patient care. Despite reporting a high proportion of negative emotions (84%), respondents (59%) were not/slightly concerned about their mental health. Top concerns included a potential second wave, Canada's financial situation, worldwide solidarity, and youth mental health. Facilitators to provide emergency care included: teamwork, leadership, clear communications strategies., Conclusion: Canadian emergency physicians felt a strong sense of responsibility to care, while dealing with several ethical dilemmas. Clear communication strategies, measures to ensure safety, and appropriate emergency department setups facilitate pandemic care. Emergency physicians were not concerned about their own mental health, requiring further exploration.

Objectives: Intravenous (IV) procedures cause pain and distress in the pediatric emergency department (ED). We studied the feasibility and acceptability of virtual reality distraction for patient comfort during intravenous procedures., Methods: Children were randomized to a control (standard care) or intervention group (standard care + virtual reality). Thresholds for feasibility and acceptability (primary outcomes) were determined through a priori established criteria. The level of procedural pain (principal clinical outcome) and distress, as well as memory of pain at 24 h were collected and reported as medians (Q1, Q3) for each group., Results: 63 patients were enrolled, with a high rate of recruitment (78.8%) and game completion (90.3%). Patients, parents and, healthcare providers reported high satisfaction levels. There were no serious adverse events. Five of the 30 patients (16.7%) exposed to virtual reality reported mild side effects. Self-reported procedural pain (verbal numerical rating scale: 3 (1, 6)/10 vs 3 (1, 5.5)/10, p = 0.75) was similar between groups. Further exploratory clinical measures were reported for the intervention and control groups, respectively: self-rated distress during the procedure (Child Fear Scale: 1 (0, 2)/4 vs 2 (0, 3)/4); distress evaluated by proxy during the procedure (Procedure Behavior Check List: 8 (8, 9)/40 vs 10 (8, 15)/40); memory of pain at 24 h (VNRS: 2 (1, 3)/10 vs 4 (2, 6.5)/10)., Conclusion: The addition of virtual reality to standard care is feasible and acceptable for pain and distress management during IV procedures in the pediatric ED. Occasional mild, self-resolving side effects were observed in the intervention group. Self-reported pain during the procedure was similar between groups. CLINICALTRIALS., Gov Identifier: NCT03750578.