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syndromes such as migraine headaches or long-term illnesses. Hypnosis has
also been recommended for the acute management of burns, fractures, and
other injuries; however, its use for painful procedures in a busy ED has not
been rigorously evaluated.
Counterstimulation is a technique by which someone repetitively and
persistently rubs or touches an area of the body close to the area that is being
hurt. This technique is based on the gate theory of pain. Transmission of pain
information from dorsal horn cells occurs through a “gate,” which opens in
response to signals from the affected small fibers. The gate can be “closed”
by large neurons that are stimulated by nonpainful touching or pressing of
the skin. The theory explains why we rub our elbow when we hit it against
something: The rubbing stimulates these large fibers and suppresses the
anticipated painful sensation. Preliminary studies demonstrate effectiveness
of a quickly pulsating device, along with a cold pack, applied to the skin
proximal to a venipuncture site using the “gate theory” in order to provide
analgesia.
Restraint should not be used in lieu of appropriate sedation and analgesics
for the pediatric patient. Although proper restraint of a child for a painful
procedure does not always reduce fear or anxiety, it does allow the physician
to perform the task better. This indirectly reduces pain because fewer
attempts may be necessary to accomplish the task. One should never attempt
a painful procedure on a moving subject! The need for restraint should be
explained to the parents, who should not be involved in the actual process.
Instead, the child might be wrapped in hospital sheets around the torso and
extremities, with the parents attempting to calm the child afterward. The
wrapping technique should be monitored carefully to avoid the uncommon
complications of minor bruising, edema, or transient vascular compromise.

SPECIAL SITUATIONS
The Emotionally Labile Child
There are a number of issues the clinician faces when caring for an injured

child who is known to be emotionally labile. This includes children with
autism, developmental delay, behavioral disorders, or an adjustment
disorder. It is important to assess the child’s expected emotional response in
a foreign environment, use the social and emotional support available to the