Presentation on theme: "The Ouchless Emergency Department"— Presentation transcript:
1 The Ouchless Emergency Department Bruce Minnes MD, FRCPCStaff Physician and Assistant Professor, Division of Paediatric Emergency MedicineChief Medical Editor, AboutKidsHealthSickKids 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 ObjectivesAt the end of this session you will be able to:Recognize the need for appropriate pain management in the emergency departmentIdentify techniques for pain assessmentIncorporate 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?3Pain causes negative emotions such as fear, anxiety, sadness, and separation2Children’s pain is often underestimated…why?3On 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 toolInability 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%)1Iatrogenic oligoanalgesia:>50% of hospitalized children receive inadequate pain management2Only 1 out of 4 children had pain management during painful procedures3Pain 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 medicationsNarcotics 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 damage1Physiological, behavioral, emotional, developmental, and sociocultural components1Needle puncture is among the most feared experiences (posttraumatic stress disorder can occur!)For our purposes: distress + anxiety included within painPain 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)
9 Why Treat Pain? Alleviate suffering Reduction in child and parent anxietyIncreased compliance and cooperation of childReduction in long term negative effects of painAlleviate suffering – moral obligation of physiciansIncreased compliance – reduction in burden on medical staff and resourcesLong term negative consequences
10 Recognition and Treatment of Pain Better understanding of painChanges in attitudeIntroduction of ‘pain services’ in hospitalsUnder treatment of pain in children remains an issueOver the past 20 years there have been improvements in recognition and treatment of painPlethora 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 thousandsEland review of literature in 1975 – 33 articles in pain in childrenGardiola and Banyos – review of literature between 1981 – 1990 – 2966 articlesWith better understanding of pain there has been a shift in attitudes and myths regarding pain in childrenHowever, there is still progress to be madeThe 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 counterpartsYounger children generally receive less analgesia than older childrenChildren receive less medication than prescribed regardless of reported pain levelMany children endure unacceptable levels of pain during hospitalization
12 Pain in the Emergency Department Self Report of Pain Survey533 school age children50 % pain due to MSK injuryMean pain intensity 5.2At discharge 4.122 % reported worsening pain, 26 % pain remained same23 % reported pain intensity ≥ 8/10Johnston CC. Pediatr Emerg Care May 2005.533 children ages yrs.
13 Pain in the Emergency Department Only 39% received analgesics during the visit11% were given a prescription foranalgesics at dischargeJohnston CC. Pediatr Emerg Care May 2005.
14 Analgesics by Age Very Young (%) 6 mo – 24 mo School Age (%) 6 – 10 yrsAll Fractures29.451.3Displacedfractures4578.1All Burns5075Second degree burns57.166.7Retrospective chart review between 1999 – 2000 in a pediatric emergency departmentThis study looked at the administration of analgesics by age.Children 6 – 24 mo vs. school age children 6 – 10 yearsLong bone fractures; burns180 research subjects; 96 in very young group; 84 in school age groupOffered analgesics; OTC or narcotics (on chart)When analgesics were given very young patients were less likely to receive narcotics compared with school age childrenChildren less than 2 years receive disproportionately less analgesia than school age children despite having obviously painful conditionsAlexander J, Manno M. Ann Emerg Med 2003
15 Parental Administration of Analgesics for Limb Injuries 72 % of parents tried to relieve pain44% non-pharmacologic methods e.g. ice28 % used analgesicsAverage pain score 6.7 +/- 2.7Concern analgesics would mask signs and symptoms, believed child not in pain, did not want to delay treatmentMaimon et al. Pediatr Emerg Care 2007146 (68 %) fracture; 68 (32 %) STIAverage time to receive medication by parent was 3.7 +/- 6 hrsAverage 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 notYounger children received less medication than older children
16 Long Term Effects of Pain Conditioned anxiety responsesIncreased response to painDiminished analgesic response at subsequent visits“Blood-injection-injury phobia”Affects 10 % of adult populationBlenophobia
17 Effects of Pain Circumcision male infants No analgesia vs. analgesiaIncreased response to immunizations at 4 to 6 monthsTaddio et al. Lancet 1997;Children undergoing bone marrow or LPPlacebo vs. analgesia initiallySubsequent procedures all received analgesicsIf received placebo initially, consistently rated pain of subsequent procedures higherWeisman 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 procedureMinimization of handling and procedures in premature infants associated with decreased incidence of intraventricular hemorrhageAls et al, 1994Former 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 diagnosisDelay in treatmentHeightened parental and patient anxiety levelBusy, fast-paced environmentA 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 diagnosisTopical anesthetics are often not used because of concerns regarding delay in definitive treatment, cost or lack of availabilityUntil 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 SignPhysiological measuresNon-specific↑ HR, RR, BP, autonomic responsesBehavioural observationSelf reportChoose developmentally appropriate toolsPain 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. sleepBehavioral scales may under represent intensity of persistent pain, as compared with self reportsPhysiologic 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 hypoxemiaAutonomic responses –Self reportSelf report is still the gold standard. It can be used in children as young as 3 years, however, developmentally appropriate tools are neededAutonomic nervous system activation“Fight or flight” response – tachycardia, peripheral vasoconstriction, diaphoresis, pupil dilatation and increased secretion of catecholamines, and adrenocorticoid hormonesLack specificity; most useful in those incapable of self report due to cognitive immaturity, impairment, illness or disabilityPrecise measurement is invasive, expensive and slowNo 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 flowAutonomic 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 wordse.g. “ow,” “hurt,” “ouch”3 – 4 yearsDegree of pain can be reported> 6 yearsDetailed description of pain quality, intensity, location
21 Pain ScoresUse of pain score in triage improves use of analgesia (25 % → 36 %)Nelson et al. Am J Emerg Med 2004Documentation 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 scaleFACES scaleNumerical scaleWord scalePain scores are not reliable in younger children
23 FLACC TOTAL SCORE between 0-10 Categories 1 2 FACE 12FACENo particular expression or smileOccasional grimace or frown, withdrawn, disinterestedFrequent to constant quivering chin, clenched jawLEGSNormal position or relaxedUneasy, restless, tenseKicking or legs drawn upActivityLying quietly, normal position, moves easilySquirming, shifting back and forth, tenseArched, rigid or jerkingCryNo cry (awake or asleep)Moans or whimpers, occasional complaintCrying steadily, screams or sobs, frequent complaintsConsolabilityContent, relaxedReassured by occasional touching, hugging or being talked to, distractedDifficult to console or comfortFor ages 2 months to 7 years, may be helpful for cognitively impaired children.Clinician should observe child for 1-5 minutesA 5-item checklist measuring facial expression, leg movement, activity level, cry and consolability to a maximum score of 10TOTAL SCORE between 0-10Merkel, SL et al. Pediatric Nursing 1997;23:
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 painAble to count up to 10, understand classification and seriationlanguage 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”
28 Non-Pharmacologic Strategies EnvironmentDistraction TechniquesChild Life SpecialistAppropriate environment essential to minimizing pain; child friendly, colourful walls, private rooms, collection of toys and gamesEach patient should have private room; colourful walls, friendly, calming environmentCollection of toys and booksParental 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 thischild’s pain?Acetaminophen PO/PRFentanyl INAcetaminophen + Codeine POMorphine IVAcetaminophen PO + IV morphine
30 Ladder Effect Pain Severity Agent of Choice Mild Pain Acetaminophen +/- NSAIDModerate PainAcetaminophen +/- NSAID + low dose morphineSevere PainAcetaminophen +/- NSAID morphine or other strong opioid
31 NSAIDS and Acetaminophen Little advantage of injected vs. oralGood post-operative analgesiaExcept tonsillectomy -> bleedingAcetaminophenOral vs. rectalRectaldelayed and variable uptake, prolonged clearanceSingle dose 30 – 40 mg/kg , neonates 20 mg/kgDo not exceed daily cumulative doseStudies show variable outcomes in comparing analgesic effectiveness of NSAIDS to acetominophenNSAIDSSystematic reviews have found little advantage of injected vs oral NSAIDSAdverse renal or GI effects rare for short term useIncrease risk of bleeding after tonsillectomyNSAIDS provide good post-operative analgesia and result in lower opioid requirement than in control groupsAcetaminophen 10 – 15 mg/kg q 4 hRectal 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 hoursSingle doses of 20 mg/kg safe in neonatesDaily 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 palatableDoseCodeine 1 mg/kg q 4 hOral Morphine 0.3 mg/kg q 4 h> 50 kg 10 – 20 mg q 4 hCodeinegenetic defect of cytochrome p450 subtype 2D6 which converts codeine to morphine may render codeine ineffective as an analgesicConverted to morphine in the liver10 % converted to morphineNausea and vomitingOxycodoneLess GI side effectsMore palatableDoes not release histamine; ? Less sedatingDose 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 circulationHydromorphone (dilaudid) is 8 times more potent and has a oral: parenteral ratio of roughly 3:1 to 4:1
33 Intravenous OpioidsMost flexible and widely used for moderate to severe painNo ceiling effectMorphine still the gold standardFentanyl ideal for proceduresMeperidine generally avoid due to side effectsOpioids are the most flexible and widely used agents for moderate to severe painOpioids have no ceiling effect unlike NSAIDS in which maximum dose of an NSAID is achieved no additional analgesic benefit is derivedOpioids – increasing dose generates more analgesic effectMorphine is the gold standardHalf life of morphine 9 hours in preterm neonates, 6.5 hours in term neonates and 2 hours in older infants and childrenDealyed renal clearance of morphine metabolites may contribute to the analgesic, respiratory depressant and rarely convulsant effects of morphine in the neonateMeperidineMetabolite normeperidine is problematic because can cause hallucinations, agitation, and seizuresMeperidine can also cause catastrophic interactions when used in conjunction with monamine oxidase inhibitorsContrary to popular belief, meperidine does not offer advantages over morphine in terms of sphincter of Oddi pressure or bowel motilityTransmucosal fentanyl – not available in CanadaTransdermal fentanyl – contraindicated as initial treatmentToxicity prevalent with prolonged useNormeperidine (metabolite) half potency of meperidine but twice the CNS excitation effects->seizures, myoclonus and agitationAvoid use of MAO-I->CNS depression, hyperpyrexia, hypo or hypertensionTachycardiaAvoid in heart disease, conduction abnormalities (SVT)Hydromorphone – derivative of morphine, more potent, also known as palladone and dilaudid, less nausea that morphine
35 Intranasal Fentanyl Painless administration of analgesia Equivalent to IV morphine for painOnset 5 minDose 1.4 mcg/kgNo serious adverse effectsBorland, M. et al. Ann Emerg Med 2007RCT IV morphine vs IN fentanyl67 patient ages 7 – 16 yearFracturesVASExclusion – 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 narcoticmedications?TrueFalse
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 agentsTend to withhold opiates or prescribe inadequate doseSickle 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 childrenWithhold opiates or prescribe inadequate dosingFear of adverse effectsRespiratory depression, hypotensionAddiction (less than 1 % (0.2 – 2 %) in children with sickle cell diseaseMask symptoms
38 Opioids Half-life of morphine Preterm 9 h, neonates 6.5 h Older infants and children 2 hNo difference in analgesic or ventilatory depressant effects in infants > 3 – 6 moImmature respiratory-reflex responses to airway obstruction, hypercapnia and hypoxemia at birthContinuous monitoring!Infants and children receiving morphine should have continuous monitoring – can’t rely on respiratory rate monitoring alone as an adequate predictor of apneaNo difference in analgesic or ventilatory depressant effects in infants > 3 – 6 months vs. adults with similar plasma concentrationsImmature respiratory-reflex responses to airway obstruction, hypercapnia and hypoxemia at birthMatures gradually over 2 – 3 months
39 Question Which of the following are effective pain management strategies in neonates?PacifiersSkin-to-skin contact with motherSucrose solutionEMLAAll of the above
40 Developmental Issues Nociception in the newborn Ascending pathways fully developedDescending inhibitory pathways not establishedEffects of repeated painful stimuli“Windup” of nociceptive neurons in dorsal hornHyperalgesia – increase sensitivity to subsequent painful stimuliUntil the late 1980’s neonates often underwent specific surgeries without analgesiaAlthough ascending pathways for pain transmission fully developed in neonate, descending inhibitory pathways are not establishedThus 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 hornIncrease 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 sticksRoberts et al. Peds 2002;Pacifier, skin to skin contact with mother, breastfeedingWhat is the upper limit of age?Heels sticks more painful than venipunctureUse of EMLA is safe in newborns and even preterm infantsSucrose has been shown to reduce response to noxious stimuli such as heel sticksThe effect is strongest in the newborn and decreases gradually over the first 6 months of lifeNursing protocols allow the use of sucrose for painful procedures in many hospitalsIt 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 venipunctureSkin to skin contact of an infant with his or her mother and breastfeeding during a procedure also decrease pain behaviors associated with painful stimuliHave 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 tongueTolerance does not develop? Ad lib to 4 times/dayPreservatives (methylparaben and potassium sorbate) used to minimize bacterial growth
43 Question In the emergency setting, narcotic analgesics may mask symptomsor cloud mental status and should beavoided until there is a clear diagnosis.TrueFalse
44 Analgesia and Acute Abdominal Pain BarriersSubjective perception of pain by physiciansConcern for surgical misdiagnosis“Disapproval of surgeon” - withholding analgesia before surgical evaluationDelay in diagnosisKim MK et al. Peds 2003;112:
45 Analgesia and Acute Abdominal Pain RCT: 60 children 5 – 18 yrs. with abdominalpain requiring surgical evaluationMorphine provided significant pain reductionNo adverse effect on patient examinationNo effect on the ability to identify children with surgical conditionsKim 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 salineED physician and surgical consultant independently assessed percussion tenderness before medica6ation and then 15 – 30 minutes after medication60 patients enrolledMedian reduction in pain score was 2 between the two groupsNo significant change in areas of tenderness in both study groups; children with surgical conditions had persistent tenderness to palpation and percussionAll patients requiring laparatomy were identified and no significant complication was noted in the morphine group
46 Analgesia and Acute Abdominal Pain 438 children evaluated84 % no appendicitis; 16 % appendicitis26 % of children received analgesicsAnalgesia given more often if high probability of appendicitis – 60 %Most received acetaminophen, few received morphine14 % 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 yrsMorphine vs placeboNo difference in:diagnosis of appendicitisperforated appendicitischildren who were initially observed → laparotomyMean reduction in pain score 2.2 vs 1.2 in the placebo groupGreen RS et al. Ann Emerg Med 2003;42:4:S87.
48 Analgesics and Evaluation Can use morphine for pain without affecting diagnostic accuracyUse 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 effectiveB. Application requires a doctors orderShould only be applied by nursesD. May increase difficulty of IVinsertion
50 Topical Anesthetics Application at triage 70 % accuracy in predicting need for IVFein A et al. Peds 1999;104:2:e19.Although wait time not reduced, parental perception of care starting at arrival associated with improved patient satisfactionImproved perception of staff’s caring and attitude toward patientsThompson DA et al. Ann Emerg Med 1996;28:
51 Topical Anesthetics EMLA® AMETOP ® MAXILENE ® Lidocaine & prilocaine 4 % tetracaine4 % liposomal lidocaineOnset of Action (min)60Duration of Action (hrs)1 – 2Up to 4-6Adverse effectsBlanching, erythema,Erythema,pruritisIrritation, itching
52 Liposomal Lidocaine Lidocaine Placebo 75 % 55% 6.5 min 8.5 min 151 patients ages 1 mo – 17 yrsLower pain scores vs. placeboMinimal vasoactive propertiesLidocainePlaceboIV firstattempt75 %55%Duration of procedure6.5 min8.5 minMaxilene – marketed in canada 2003Randomized controlled trial with liposomal lidocaine vs. placeboPatients age 1 month 17 years ; 151 patientsLower pain scores with lidocaine vs. placeboIV success on first cannulation 74 % with lipsomal lidocaine vs. 55 % with placeboDuration 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 minutes75 – 80 % complete anesthesiaNot for mucous membranes, end organsSoak cottonball and apply to wound with pressureDose: 3 ml (no repeats)161 patients
54 1 % Lidocaine Dosage 5 mg/kg 7 mg/kg with epinephrine Strategies to reduce pain with injectionSmall, long needle (30 G)Inject slowlyBuffered solution: add 1ml NaHCO3 to 9 ml lidocaine solutionStable at room temperature for 1 weekWarm solution (40 – 42 °C)
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 painDistraction and comfortPhysical strategies: sling, splint, cool pack, etc…Administer analgesics!If pain anticipated then treat prophylactaly inhumane to wait.dev appropriate assessment should be madeother approaches such as cognitive.behavioural. emotionalThe route should not cause pain as much as possible