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The Ouchless Emergency Department Bruce Minnes MD, FRCPC Staff Physician and Assistant Professor, Division of Paediatric Emergency Medicine Chief Medical.

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Presentation on theme: "The Ouchless Emergency Department Bruce Minnes MD, FRCPC Staff Physician and Assistant Professor, Division of Paediatric Emergency Medicine Chief Medical."— Presentation transcript:

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 separation 2 Children’s pain is often underestimated…why? 3 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 management 2 Only 1 out of 4 children had pain management during painful procedures 3 1: Taylor EM, et al. (2008), 2: Stinson J, et al. (2008), 3: Stevens, BJ. et al. (2011)

6 Pain: 5 Myths 1.“If it doesn’t kill you it makes you stronger” or, “No pain, no gain”. 2.It’s all in their heads. 3.Children don’t feel pain in the same way or at all (or forget about it quickly). 4.The only way to manage pain is with strong medications 5.Narcotics pose a high risk of dependency or adverse effects in children.

7 Background - Defining Pain Unpleasant sensory and emotional experience associated with actual or potential tissue damage 1 Physiological, behavioral, emotional, developmental, and sociocultural components 1 Needle puncture is among the most feared experiences (posttraumatic stress disorder can occur!) For our purposes: distress + anxiety included within pain 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

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

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.

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 Fractures29.451.3 Displaced fractures 4578.1 All Burns5075 Second degree burns 57.166.7 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

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

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; 599-603. 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;147-149.

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

19 Approaches to Pain Assessment Pain assessment – 5 th Vital Sign Physiological measures – Non-specific – ↑ HR, RR, BP, autonomic responses Behavioural observation Self report – Choose developmentally appropriate tools

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 yearsDetailed 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? 1.FLACC scale 2.FACES scale 3.Numerical scale 4.Word scale 5.Pain scores are not reliable in younger children

23 Categories012 FACENo particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw LEGSNormal position or relaxed Uneasy, restless, tenseKicking or legs drawn up ActivityLying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid or jerking CryNo cry (awake or asleep) Moans or whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints ConsolabilityContent, relaxedReassured by occasional touching, hugging or being talked to, distracted Difficult to console or comfort TOTAL SCORE between 0-10 Merkel, SL et al. Pediatric Nursing 1997;23: 293-297. FLACC

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.

25 Word Scale Ask the child to classify the pain into one of 4 categories “none” “a little” “medium” “a lot”

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?”

27 Management Strategies Non-pharmacologic Pharmacologic – Analgesics – Sedative

28 Non-Pharmacologic Strategies Environment Distraction Techniques Child Life Specialist 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? A.Acetaminophen PO/PR B.Fentanyl IN C.Acetaminophen + Codeine PO D.Morphine IV E.Acetaminophen PO + IV morphine

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

31 NSAIDS and Acetaminophen NSAIDS – 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

32 Oral Morphine vs Codeine – Only 10 % of codeine converted to morphine – “Non-metabolizers” and “extensive metabolizers” – Less GI side effects, more palatable Dose – Codeine1 mg/kg q 4 h – Oral Morphine0.3 mg/kg q 4 h > 50 kg 10 – 20 mg q 4 h

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

34 Relative Potencies of Intravenous Opioids Drug Morphine Fentanyl Hydro- morphone IV Dose (mg/kg) 0.1 0.001 0.015-0.02 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

36 Question Children are more sensitive to the potential side effects of narcotic medications? A.True B.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 %)

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!

39 Question Which of the following are effective pain management strategies in neonates? 1.Pacifiers 2.Skin-to-skin contact with mother 3.Sucrose solution 4.EMLA 5.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

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;1053-7. Pacifier, skin to skin contact with mother, breastfeeding What is the upper limit of age?

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

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. 1. True 2. 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;112:1122-26.

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;281-287.

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 C. 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;28:657-665.

51 Topical Anesthetics EMLA®AMETOP ®MAXILENE ® Lidocaine & prilocaine 4 % tetracaine 4 % liposomal lidocaine Onset of Action (min) 6030 - 4520 - 30 Duration of Action (hrs) 1 – 2Up to 4-61 – 2 Adverse effects Blanching, erythema, Erythema, pruritis Irritation, itching

52 Liposomal Lidocaine 151 patients ages 1 mo – 17 yrs Lower pain scores vs. placebo Minimal vasoactive properties LidocainePlacebo IV first attempt 75 %55% Duration of procedure 6.5 min8.5 min Taddio A et al. CMAJ 2005:1691-95.

53 LET for Laceration Repair (Lidocaine 4 %, Epinephrine 0.1 %, Tetracaine 0.5 %) Application time 20 - 30 minutes 75 – 80 % complete anesthesia Not for mucous membranes, end organs Soak cottonball and apply to wound with pressure Dose: 3 ml (no repeats)

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 – 5 th vital sign Anticipate painful procedures/conditions and identify strategies to manage pain Distraction and comfort Physical strategies: sling, splint, cool pack, etc… Administer analgesics!

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