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The Ouchless Emergency Department

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1 The Ouchless Emergency Department
Bruce Minnes MD, FRCPC Staff Physician and Assistant Professor, Division of Paediatric Emergency Medicine Chief Medical Editor, AboutKidsHealth SickKids and The University of Toronto

2 Disclosure and Acknowledgement
I have no conflict of interest to declare. I don’t like pain. Thanks to Dr. Suzan Schneeweiss and to the 2011 IPEME students from Canada and various parts of the Middle East

3 Learning Objectives At the end of this session you will be able to: Recognize the need for appropriate pain management in the emergency department Identify techniques for pain assessment Incorporate pain management strategies in the emergency department

4 Background - General “The relief of pain should be a human right”1
Children do not feel pain the same way adults…a myth?3 Pain causes negative emotions such as fear, anxiety, sadness, and separation2 Children’s pain is often underestimated…why?3 On October 11, 2004, the Global Day Against Pain, the World Health Organization’s International Association for the Study of Pain and the European Federation of the International Association for the Study of Pain Chapters issued a joint declaration supporting that “the relief of pain should be a human right”(1). Lack of adequate assessment tool Inability to consider pain in different stages of children’s developmental stages. 1: Taylor, EM et al. (2008), 2: Yoo, H et al. (2011), 3: Zempsky et al. (2006)

5 Background - Epidemiology
Pain is major and common complaint in hospitals (>75%)1 Iatrogenic oligoanalgesia: >50% of hospitalized children receive inadequate pain management2 Only 1 out of 4 children had pain management during painful procedures3 Pain is major and common complaint in the hospital setting. Among admissions, more than 3 out 4 patients experienced pain during admission (1). Additionally, 42% of the children who had experienced pain during admission had received no analgesia (1). Over the past 15 years, epidemiological surveys have consistently emphasized that a significant proportion (49% to 64%) of hospitalized children receive inadequate pain management despite the increase in knowledge and available treatments(2). In a study by Stevens et al. (2011), only one out of four of the children had one or more pain management interventions administered and documented specifically for a painful procedure (3). 1: Taylor EM, et al. (2008), 2: Stinson J, et al. (2008), 3: Stevens, BJ. et al. (2011)

6 Pain: 5 Myths “If it doesn’t kill you it makes you stronger” or, “No pain, no gain”. It’s all in their heads. Children don’t feel pain in the same way or at all (or forget about it quickly). The only way to manage pain is with strong medications Narcotics pose a high risk of dependency or adverse effects in children. Pain Relief Myth 1: No Pain, No Gain. This myth persists among bodybuilders and weekend athletes. Yet there is no evidence to support the notion that you can build strength by exerting muscles to the point of pain. A related belief, "Work through the pain," is also mistaken. Resting to repair muscles and bring pain relief might not be macho, but it's a smart thing to do. You may also need to modify your exercise routine with cross training; lighter, more frequent workouts; and proper shoes. Pain Relief Myth 2: It's All In My Head. Pain is a complex problem, involving both the mind and the body. For instance, back pain has no known cause in most cases, and stressful life events can make it worse. But that doesn't mean it isn't real. Pain is an invisible problem that others can't see, but that doesn't mean it's all in your head. Pain Relief Myth 3: I Just Have to Live with the Pain. There are countless options for pain relief. They include relaxation techniques, exercise, physical therapy, glucosamine supplements, over-the-counter and prescription medications, surgery, and complementary treatments such as acupuncture and massage. It may not always be possible to completely control your pain, but you can use many techniques to help you manage it much better. Pain Relief Myth 4: Only Sissies Go to the Doctor for Pain Relief. Older adults are more prone than their kids or grandkids to "grin and bear it." Enduring the occasional headache or minor sports injury is one thing. But putting up with chronic pain can impair your functioning and quality of life. It can lead to depression, fatigue from loss of sleep, anxiety, inability to work, and impaired relationships. Most pain can be treated effectively and should be. If you are suffering from pain, you owe it to yourself to make an appointment with your doctor. Relief may be just around the corner. Pain Relief Myth 5: I'll Get Addicted to the Pain Medication. Health care providers begin with a conservative approach to pain relief and prescribe non-narcotic pain-relief medications, which are not addictive. Doctors may prescribe narcotics, such as codeine and morphine, if pain becomes severe, such as when treating cancer pain. Many people fear that they will become addicted to narcotics. Physical dependence is not the same thing as addiction. And, physical dependence isn't a problem as long as you do not stop taking the narcotics suddenly. Addiction is rarely a problem, unless you have a history of drug or alcohol addiction. If you do, discuss this with your health care provider.

7 Background - Defining Pain
Unpleasant sensory and emotional experience associated with actual or potential tissue damage1 Physiological, behavioral, emotional, developmental, and sociocultural components1 Needle puncture is among the most feared experiences (posttraumatic stress disorder can occur!) For our purposes: distress + anxiety included within pain Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (5). It is also generally acknowledged that pain is a highly personal and complex experience comprising of physiological, behavioral, emotional, developmental, and sociocultural components (5). In the context of pediatric medical procedures, in addition to causing physical pain, they are often a source of anxiety, fear, and behavioral distress for children and their families (5). These psychological factors can further intensify the child’s pain and interfere with the procedure (5). According to the Cochrane Review by Uman et al (2011) Medical procedures, particularly needles, are among the most feared experiences of children (5). Zempsky et al (2004) found that neonates who undergo procedures with inadequate analgesia have long-standing alterations in their response to and perceptions of painful experiences (6) .For example, posttraumatic stress disorder can occur after procedures or stressful medical experiences that are not accompanied by appropriate pain control or sedation (6). 1: Uman LS, et al. (2006), 2: Zempsky et al. (2004)

8 Pain, Anxiety or Both?

9 Why Treat Pain? Alleviate suffering
Reduction in child and parent anxiety Increased compliance and cooperation of child Reduction in long term negative effects of pain Alleviate suffering – moral obligation of physicians Increased compliance – reduction in burden on medical staff and resources Long term negative consequences

10 Recognition and Treatment of Pain
Better understanding of pain Changes in attitude Introduction of ‘pain services’ in hospitals Under treatment of pain in children remains an issue Over the past 20 years there have been improvements in recognition and treatment of pain Plethora of new research in pain. Whereas in the 1970’s there were few articles related to pain in children, by the 1990’s there were thousands Eland review of literature in 1975 – 33 articles in pain in children Gardiola and Banyos – review of literature between 1981 – 1990 – 2966 articles With better understanding of pain there has been a shift in attitudes and myths regarding pain in children However, there is still progress to be made The administration of analgesia in children varies by age and lags behind our adult counterparts. There is still a wide variation in pain management practice by different EDs and health care professionals

11 ‘Oligoanalgesia’ Children receive less analgesia than adult counterparts Younger children generally receive less analgesia than older children Children receive less medication than prescribed regardless of reported pain level Many children endure unacceptable levels of pain during hospitalization

12 Pain in the Emergency Department
Self Report of Pain Survey 533 school age children 50 % pain due to MSK injury Mean pain intensity 5.2 At discharge 4.1 22 % reported worsening pain, 26 % pain remained same 23 % reported pain intensity ≥ 8/10 Johnston CC. Pediatr Emerg Care May 2005. 533 children ages yrs.

13 Pain in the Emergency Department
Only 39% received analgesics during the visit 11% were given a prescription for analgesics at discharge Johnston CC. Pediatr Emerg Care May 2005.

14 Analgesics by Age Very Young (%) 6 mo – 24 mo School Age (%)
6 – 10 yrs All Fractures 29.4 51.3 Displaced fractures 45 78.1 All Burns 50 75 Second degree burns 57.1 66.7 Retrospective chart review between 1999 – 2000 in a pediatric emergency department This study looked at the administration of analgesics by age. Children 6 – 24 mo vs. school age children 6 – 10 years Long bone fractures; burns 180 research subjects; 96 in very young group; 84 in school age group Offered analgesics; OTC or narcotics (on chart) When analgesics were given very young patients were less likely to receive narcotics compared with school age children Children less than 2 years receive disproportionately less analgesia than school age children despite having obviously painful conditions Alexander J, Manno M. Ann Emerg Med 2003

15 Parental Administration of Analgesics for Limb Injuries
72 % of parents tried to relieve pain 44% non-pharmacologic methods e.g. ice 28 % used analgesics Average pain score 6.7 +/- 2.7 Concern analgesics would mask signs and symptoms, believed child not in pain, did not want to delay treatment Maimon et al. Pediatr Emerg Care 2007 146 (68 %) fracture; 68 (32 %) STI Average time to receive medication by parent was 3.7 +/- 6 hrs Average pain score 6.7 +/-2.7; no significant difference in pain scores in child who received pain medication before coming to ED vs. those who did not Younger children received less medication than older children

16 Long Term Effects of Pain
Conditioned anxiety responses Increased response to pain Diminished analgesic response at subsequent visits “Blood-injection-injury phobia” Affects 10 % of adult population Blenophobia

17 Effects of Pain Circumcision male infants
No analgesia vs. analgesia Increased response to immunizations at 4 to 6 months Taddio et al. Lancet 1997; Children undergoing bone marrow or LP Placebo vs. analgesia initially Subsequent procedures all received analgesics If received placebo initially, consistently rated pain of subsequent procedures higher Weisman SJ et al. Arch Pediatr Adol Med 1998; Among children newly diagnosed with cancer those who had inadequate analgesia during a first bone marrow aspiration or lumbar puncture showed more severe distress during subsequent procedures than those who received a potent opioid )oral transmucocal fentanyl citrate) during the first procedure Minimization of handling and procedures in premature infants associated with decreased incidence of intraventricular hemorrhage Als et al, 1994 Former preterm infants gave higher rating of painful events than age-matched control; duration of NICU stay was correlated with higher pain ratings

18 What are the barriers in the emergency setting?
Children present with a constellation of symptoms and no final diagnosis Delay in treatment Heightened parental and patient anxiety level Busy, fast-paced environment A number of factors make the assessment and selection of the appropriate analgesic agent more difficult. Analgesics typically used for pain in other settings may not be used in the emergency department for fear of masking symptoms and prevention of appropriate diagnosis Topical anesthetics are often not used because of concerns regarding delay in definitive treatment, cost or lack of availability Until recently education in pain management has not been emphasized for clinical staff; little emphasis in undergraduate or graduate medical education

19 Approaches to Pain Assessment
Pain assessment – 5th Vital Sign Physiological measures Non-specific ↑ HR, RR, BP, autonomic responses Behavioural observation Self report Choose developmentally appropriate tools Pain assessment is the key to good management. Behavioral observational scales are the primary method of pain assessment in neonates and infants and children under four years of age or for children with developmental disabilities. Behavioral indicators encompass facial expression, cry, gross motor movement, changes in behavioral state, and changes in behavioral pattern eg. sleep Behavioral scales may under represent intensity of persistent pain, as compared with self reports Physiologic indexes of pain are useful during surgery and in the intensive care unit, although they may be non-specific e.g. tachycardia may be caused by hypovolemia, or hypoxemia Autonomic responses – Self report Self report is still the gold standard. It can be used in children as young as 3 years, however, developmentally appropriate tools are needed Autonomic nervous system activation “Fight or flight” response – tachycardia, peripheral vasoconstriction, diaphoresis, pupil dilatation and increased secretion of catecholamines, and adrenocorticoid hormones Lack specificity; most useful in those incapable of self report due to cognitive immaturity, impairment, illness or disability Precise measurement is invasive, expensive and slow No standard pain assessment measures that rely exclusively on these parameters  HR, RR, BP  HR variability and ICP  vagal tone, transcutaneous oxygen saturation levels, transcutaneous carbon dioxide levels, peripheral blood flow Autonomic changes in skin color, nausea, vomiting, gagging, hiccoughing, diaphoresis, dilated pupils and palmer sweating

20 Pain Assessment Self report considered “gold standard” 18 – 24 months
Pain words e.g. “ow,” “hurt,” “ouch” 3 – 4 years Degree of pain can be reported > 6 years Detailed description of pain quality, intensity, location

21 Pain Scores Use of pain score in triage improves use of analgesia (25 % → 36 %) Nelson et al. Am J Emerg Med 2004 Documentation of pain scores improves analgesic administration in the ED (33 vs 60 %) Silka et al. Acad Emerg Med 2004. Triage pain assessment improves times to analgesia (2.3 →1.6 hrs) Boyd RJ and Stuart P, Emerg Med J 2005.

22 Question A 4 yr old presents with pain and swelling of the
left forearm after having tripped over a toy car. How would you assess this child’s pain? FLACC scale FACES scale Numerical scale Word scale Pain scores are not reliable in younger children

23 FLACC TOTAL SCORE between 0-10 Categories 1 2 FACE
1 2 FACE No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw LEGS Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid or jerking Cry No cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging or being talked to, distracted Difficult to console or comfort For ages 2 months to 7 years, may be helpful for cognitively impaired children. Clinician should observe child for 1-5 minutes A 5-item checklist measuring facial expression, leg movement, activity level, cry and consolability to a maximum score of 10 TOTAL SCORE between 0-10 Merkel, SL et al. Pediatric Nursing 1997;23:

24 Faces Pain Scale – Revised (FPS-R)
Score the chosen face 0,2,4,6,8 or 10, counting left to right, so ‘0’ = no pain and ’10’ = very much pain IASP© Hicks et al. Pain 2001. FPS-R Download from website to get instructions in 24 languages Useful in preschool-school aged , or with language barrier

25 Word Scale Ask the child to classify the pain into one of 4 categories
“none” “a little” “medium” “a lot” This method can be used for preschool children who wish to use a simple approach or for older children unable to use other scales. Simply ask the child to classify their pain as none, a little, medium or a lot. Ask “How much pain/hurt are you having now?”

26 Numerical Rating Scale 0-10
>7 years for procedural, acute and chronic pain Able to count up to 10, understand classification and seriation language comprehension “If 0 is no pain/hurt and 10 is the worst pain imaginable, how much pain are you having right now?” A commonly used tool at HSC. For school-aged children and adolescents. The child must understand the anchors of no pain (0) and worst pain (10). Ensure that the child does not have the scale reversed in his/her mind. For example the child may think that 10 , since it is a high number, is better than 0, and may interpret that 10 means “no pain”

27 Management Strategies
Non-pharmacologic Pharmacologic Analgesics Sedative

28 Non-Pharmacologic Strategies
Environment Distraction Techniques Child Life Specialist Appropriate environment essential to minimizing pain; child friendly, colourful walls, private rooms, collection of toys and games Each patient should have private room; colourful walls, friendly, calming environment Collection of toys and books Parental Presence during procedure

29 Question An 18 month old boy sustained second degree burn on his chest
after spilling hot tea from a cup. He is crying inconsolably. How would you manage this child’s pain? Acetaminophen PO/PR Fentanyl IN Acetaminophen + Codeine PO Morphine IV Acetaminophen PO + IV morphine

30 Ladder Effect Pain Severity Agent of Choice Mild Pain
Acetaminophen +/- NSAID Moderate Pain Acetaminophen +/- NSAID + low dose morphine Severe Pain Acetaminophen +/- NSAID morphine or other strong opioid

31 NSAIDS and Acetaminophen
Little advantage of injected vs. oral Good post-operative analgesia Except tonsillectomy -> bleeding Acetaminophen Oral vs. rectal Rectal delayed and variable uptake, prolonged clearance Single dose 30 – 40 mg/kg , neonates 20 mg/kg Do not exceed daily cumulative dose Studies show variable outcomes in comparing analgesic effectiveness of NSAIDS to acetominophen NSAIDS Systematic reviews have found little advantage of injected vs oral NSAIDS Adverse renal or GI effects rare for short term use Increase risk of bleeding after tonsillectomy NSAIDS provide good post-operative analgesia and result in lower opioid requirement than in control groups Acetaminophen 10 – 15 mg/kg q 4 h Rectal produces delayed and variable uptake; single does of 34 – 45 mg/kg generally produce therapeutic plasma concentration with prolonged clearance; subsequent doses should be smaller (20 mg/kg) and the interval between does should be extended to at least 6 – 8 hours Single doses of 20 mg/kg safe in neonates Daily cumulative acetaminophen doses by oral or rectal route should not exceed 100 mg/kg children, 75 mg/kg in infants and 60 mg/kg in neonates

32 Oral Morphine vs Codeine
Only 10 % of codeine converted to morphine “Non-metabolizers” and “extensive metabolizers” Less GI side effects, more palatable Dose Codeine 1 mg/kg q 4 h Oral Morphine 0.3 mg/kg q 4 h > 50 kg 10 – 20 mg q 4 h Codeine genetic defect of cytochrome p450 subtype 2D6 which converts codeine to morphine may render codeine ineffective as an analgesic Converted to morphine in the liver 10 % converted to morphine Nausea and vomiting Oxycodone Less GI side effects More palatable Does not release histamine; ? Less sedating Dose 0.1 mg/kg q 3- 4 h; child > 50 kg 5 – 10 mg q 3 – 5 hours (equipotent dose to 10 mg IV morphine = 15 – 20 mg) Oral morphine = 0.3 mg/kg q 3 – 4 h; child > 50 kg 10 – 20 mg q 3 – 4 h (equipotent dose to 10 mg IV morphine = 60 mg; with chronic use 30 mg because of effects on the enterohepatic circulation Hydromorphone (dilaudid) is 8 times more potent and has a oral: parenteral ratio of roughly 3:1 to 4:1

33 Intravenous Opioids Most flexible and widely used for moderate to severe pain No ceiling effect Morphine still the gold standard Fentanyl ideal for procedures Meperidine generally avoid due to side effects Opioids are the most flexible and widely used agents for moderate to severe pain Opioids have no ceiling effect unlike NSAIDS in which maximum dose of an NSAID is achieved no additional analgesic benefit is derived Opioids – increasing dose generates more analgesic effect Morphine is the gold standard Half life of morphine 9 hours in preterm neonates, 6.5 hours in term neonates and 2 hours in older infants and children Dealyed renal clearance of morphine metabolites may contribute to the analgesic, respiratory depressant and rarely convulsant effects of morphine in the neonate Meperidine Metabolite normeperidine is problematic because can cause hallucinations, agitation, and seizures Meperidine can also cause catastrophic interactions when used in conjunction with monamine oxidase inhibitors Contrary to popular belief, meperidine does not offer advantages over morphine in terms of sphincter of Oddi pressure or bowel motility Transmucosal fentanyl – not available in Canada Transdermal fentanyl – contraindicated as initial treatment Toxicity prevalent with prolonged use Normeperidine (metabolite) half potency of meperidine but twice the CNS excitation effects ->seizures, myoclonus and agitation Avoid use of MAO-I ->CNS depression, hyperpyrexia, hypo or hypertension Tachycardia Avoid in heart disease, conduction abnormalities (SVT) Hydromorphone – derivative of morphine, more potent, also known as palladone and dilaudid, less nausea that morphine

34 Relative Potencies of Intravenous Opioids
Drug Morphine Fentanyl Hydro- morphone IV Dose (mg/kg) 0.1 0.001 Frequency (hours) 2 – 4 1 – 2 2 - 4 Ratio of Equivalence to morphine 1 80 – 100 5 - 7

35 Intranasal Fentanyl Painless administration of analgesia
Equivalent to IV morphine for pain Onset 5 min Dose 1.4 mcg/kg No serious adverse effects Borland, M. et al. Ann Emerg Med 2007 RCT IV morphine vs IN fentanyl 67 patient ages 7 – 16 year Fractures VAS Exclusion – narcotic within 4 hours of arrival, significant head injury, allergy to opiates, nasal blockage, inability to perform pain score

36 Question Children are more sensitive to the potential
side effects of narcotic medications? True False

37 Narcotics and Pain in Children
Pain underestimated because of fear of over-sedation, respiratory depression, addiction and unfamiliarity with use of sedative and analgesic agents Tend to withhold opiates or prescribe inadequate dose Sickle cell and addiction < 1% (0.2 – 2 %) Pain is often underestimated because of fear of oversedation, respiratory depression and addiction and unfamiliarity with use of sedative and analgesic agents in children Withhold opiates or prescribe inadequate dosing Fear of adverse effects Respiratory depression, hypotension Addiction (less than 1 % (0.2 – 2 %) in children with sickle cell disease Mask symptoms

38 Opioids Half-life of morphine Preterm 9 h, neonates 6.5 h
Older infants and children 2 h No difference in analgesic or ventilatory depressant effects in infants > 3 – 6 mo Immature respiratory-reflex responses to airway obstruction, hypercapnia and hypoxemia at birth Continuous monitoring! Infants and children receiving morphine should have continuous monitoring – can’t rely on respiratory rate monitoring alone as an adequate predictor of apnea No difference in analgesic or ventilatory depressant effects in infants > 3 – 6 months vs. adults with similar plasma concentrations Immature respiratory-reflex responses to airway obstruction, hypercapnia and hypoxemia at birth Matures gradually over 2 – 3 months

39 Question Which of the following are effective pain
management strategies in neonates? Pacifiers Skin-to-skin contact with mother Sucrose solution EMLA All of the above

40 Developmental Issues Nociception in the newborn
Ascending pathways fully developed Descending inhibitory pathways not established Effects of repeated painful stimuli “Windup” of nociceptive neurons in dorsal horn Hyperalgesia – increase sensitivity to subsequent painful stimuli Until the late 1980’s neonates often underwent specific surgeries without analgesia Although ascending pathways for pain transmission fully developed in neonate, descending inhibitory pathways are not established Thus painful stimuli may reach the brain without modulation leading to more pronounced pain sensation in neonates than in children than adults “windup” of neuron in the the dorsal horn – increase excitability of the nocieptive neurons in the dorsal horn Increase sensitivity to subsequent painful stimuli, not only from procedures, but also from routine handling of infants

41 Neonatal Pain Management
Topical anesthetics are SAFE! Sucrose (12 – 25 %) / Glucose (30 %) Oral glucose more effective than EMLA for heel sticks Roberts et al. Peds 2002; Pacifier, skin to skin contact with mother, breastfeeding What is the upper limit of age? Heels sticks more painful than venipuncture Use of EMLA is safe in newborns and even preterm infants Sucrose has been shown to reduce response to noxious stimuli such as heel sticks The effect is strongest in the newborn and decreases gradually over the first 6 months of life Nursing protocols allow the use of sucrose for painful procedures in many hospitals It can be made by the pharmacy or is commercially available e.g Sweet-Ease) Pacificer alone or in conjunctiion with sucrose has also been shown to have analgesic effects in neonates undergoing routine venipuncture Skin to skin contact of an infant with his or her mother and breastfeeding during a procedure also decrease pain behaviors associated with painful stimuli Have baby suck on finger or pacifier during procedure (glucose solution may also stimulate sucking) 50 % in both groups (EMLA vs. 30 % glucose did not suck indicating that sucking

42 Sucrose Solution Safe, easy-to-administer, inexpensive
1 – 2 mL 2 min prior to procedure on pacifier or dripped onto tongue Tolerance does not develop ? Ad lib to 4 times/day Preservatives (methylparaben and potassium sorbate) used to minimize bacterial growth

43 Question In the emergency setting, narcotic
analgesics may mask symptoms or cloud mental status and should be avoided until there is a clear diagnosis. True False

44 Analgesia and Acute Abdominal Pain
Barriers Subjective perception of pain by physicians Concern for surgical misdiagnosis “Disapproval of surgeon” - withholding analgesia before surgical evaluation Delay in diagnosis Kim MK et al. Peds 2003;112:

45 Analgesia and Acute Abdominal Pain
RCT: 60 children 5 – 18 yrs. with abdominal pain requiring surgical evaluation Morphine provided significant pain reduction No adverse effect on patient examination No effect on the ability to identify children with surgical conditions Kim MK et al. Acad Emerg Med 2002; RCT for children between 5 – 18 yrs. With abdominal pain < 5days and a need for surgical evaluation, pain score > 5, Children received either 0.1 mg/kg morphine or equal volume of saline ED physician and surgical consultant independently assessed percussion tenderness before medica6ation and then 15 – 30 minutes after medication 60 patients enrolled Median reduction in pain score was 2 between the two groups No significant change in areas of tenderness in both study groups; children with surgical conditions had persistent tenderness to palpation and percussion All patients requiring laparatomy were identified and no significant complication was noted in the morphine group

46 Analgesia and Acute Abdominal Pain
438 children evaluated 84 % no appendicitis; 16 % appendicitis 26 % of children received analgesics Analgesia given more often if high probability of appendicitis – 60 % Most received acetaminophen, few received morphine 14 % of children were underdosed (24 % with morphine) Goldman RD, et al. Pediatr Emerg Care 2006;22:1:18-21.

47 Early Analgesia in Acute Abdominal Pain
Randomized double-blind placebo controlled trial 108 children 5 – 16 yrs Morphine vs placebo No difference in: diagnosis of appendicitis perforated appendicitis children who were initially observed → laparotomy Mean reduction in pain score 2.2 vs 1.2 in the placebo group Green RS et al. Ann Emerg Med 2003;42:4:S87.

48 Analgesics and Evaluation
Can use morphine for pain without affecting diagnostic accuracy Use of pain medication allows child to be more comfortable and therefore more cooperative during a diagnostic examination .

49 Question Which of the following statements regarding the use
of topical anesthetics is true? A. Maxilene and EMLA are equally effective B. Application requires a doctors order Should only be applied by nurses D. May increase difficulty of IV insertion

50 Topical Anesthetics Application at triage
70 % accuracy in predicting need for IV Fein A et al. Peds 1999;104:2:e19. Although wait time not reduced, parental perception of care starting at arrival associated with improved patient satisfaction Improved perception of staff’s caring and attitude toward patients Thompson DA et al. Ann Emerg Med 1996;28:

51 Topical Anesthetics EMLA® AMETOP ® MAXILENE ® Lidocaine & prilocaine
4 % tetracaine 4 % liposomal lidocaine Onset of Action (min) 60 Duration of Action (hrs) 1 – 2 Up to 4-6 Adverse effects Blanching, erythema, Erythema, pruritis Irritation, itching

52 Liposomal Lidocaine Lidocaine Placebo 75 % 55% 6.5 min 8.5 min
151 patients ages 1 mo – 17 yrs Lower pain scores vs. placebo Minimal vasoactive properties Lidocaine Placebo IV first attempt 75 % 55% Duration of procedure 6.5 min 8.5 min Maxilene – marketed in canada 2003 Randomized controlled trial with liposomal lidocaine vs. placebo Patients age 1 month 17 years ; 151 patients Lower pain scores with lidocaine vs. placebo IV success on first cannulation 74 % with lipsomal lidocaine vs. 55 % with placebo Duration of procedure shorter with liposomal lidocaine. Taddio A et al. CMAJ 2005:

53 LET for Laceration Repair (Lidocaine 4 %, Epinephrine 0
LET for Laceration Repair (Lidocaine 4 %, Epinephrine 0.1 %, Tetracaine 0.5 %) Application time minutes 75 – 80 % complete anesthesia Not for mucous membranes, end organs Soak cottonball and apply to wound with pressure Dose: 3 ml (no repeats) 161 patients

54 1 % Lidocaine Dosage 5 mg/kg 7 mg/kg with epinephrine
Strategies to reduce pain with injection Small, long needle (30 G) Inject slowly Buffered solution: add 1ml NaHCO3 to 9 ml lidocaine solution Stable at room temperature for 1 week Warm solution (40 – 42 °C)

55 Pain Resource Centre

56 Health information in Arabic from AboutKidsHealth
الألم في المنزل: رعاية طفلك

57 Summary Pain assessment imperative in all patients – 5th vital sign
Anticipate painful procedures/conditions and identify strategies to manage pain Distraction and comfort Physical strategies: sling, splint, cool pack, etc… Administer analgesics! If pain anticipated then treat prophylactaly inhumane to wait. dev appropriate assessment should be made other approaches such as cognitive.behavioural. emotional The route should not cause pain as much as possible

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