Pain & Sedation
An 11 year old boy is brought to the Emergency Department after play fighting with friends at school. He tells you he fell onto his left arm. X-ray shows a fracture. You assess the patient's pain to be severe using the RCEM composite pain scoring system. What treatment is now recommended?
Answer:
For:- Mild pain
- Oral/rectal paracetamol 20 mg/kg loading dose, then 15 mg/kg 4 - 6 hourly OR
- Oral ibuprofen 10 mg/kg 6 - 8 hourly
- Moderate pain
- As for mild pain PLUS
- Oral/rectal diclofenac 1 mg/kg 8 hourly (unless already had ibuprofen) AND/OR
- Oral codeine phosphate 1 mg/kg 4 - 6 hourly (over 12 years old only) OR
- Oral morphine 0.2 - 0.5 mg/kg stat
- Severe pain
- Consider entonox as holding measure THEN
- Intranasal diamorphine 0.2 ml (= 0.1 mg/kg) FOLLOWED BY/OR
- IV morphine 0.1 - 0.2 mg/kg infused over 2 - 3 minutes
- Supplemented by oral analgesics
Paediatric Pain Management
Pain & Sedation
Last Updated: 2nd May 2021
Recognition and alleviation of pain should be a priority when treating ill and injured children. This process should start at the triage, be monitored during their time in the ED and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge.
Pain is commonly under-recognised, under-treated and treatment may be delayed. This is especially true in children. Reasons include difficulty in assessing severity, the child may not appear distressed or have difficulty describing / admitting to pain. Drug choice and dosage may also cause problems due to unfamiliarity.
Pain assessment
Pain assessment forms an integral part of the Manchester Triage Scale. Multiple assessment tools are in use. The better known uni-direction scales have some evidence in the context of an ED environment, and even where the atmosphere is tense and the child and parent are using such tools for the first time, are satisfactory for the purpose of pain assessment and management.
The pain ladder contains objective and subjective descriptions with a numerical scale. Some scales are based solely on faces, and the APLS pain ladder combines objective and subjective descriptions with panda faces. RCEM recommends the use of the attached assessment tool (see useful links) or a locally developed alternative.
The experience of the member of staff triaging the child will help in estimating the severity of the pain. In addition, we rely on visual clues such as crying or loss of movement of a limb, which can be measured by behavioural scoring systems such as the CHEOPS score, which are particularly useful in non-verbal children.
How to treat pain
- Psychological strategies:
- Parent and family member involvement
- Child-friendly environment
- Explanation with reassurance
- Distraction with toys, blowing bubbles, reading or storytelling
- Play specialist
- Non-pharmacological adjuncts:
- Limb immobilisation and elevation
- Cooling and dressings for burns
- Definitive treatment e.g. reduction of pulled elbow
- Pharmacological options:
- Analgesia
- Paracetamol
- Most widely used analgesic in paediatric practice
- May be administered by oral, rectal and intravenous routes
- Thought to work by inhibiting cyclooxygenase in the central nervous system
- NSAIDs
- Anti-inflammatory and antipyretic drugs with moderate analgesic properties
- Less well tolerated than paracetamol causing gastric irritation, platelet disorders, bronchospasm and renal impairment
- Especially useful for post-traumatic pain because of anti-inflammatory effect
- Ibuprofen is given by mouth and if rectal administration is required, diclofenac can be used
- Weak opioids e.g. codeine
- Strong opioids e.g. morphine
- Morphine administered intravenously produces a rapid onset of excellent analgesia and remains the treatment of choice in many situations
- May be titrated to effect and reversed if necessary
- Side effects include respiratory depression and nausea and vomiting
- Cardiovascular effects include peripheral vasodilation and venous pooling
- The intranasal route for the administration of opiates such as diamorphine and fentanyl has been shown to be a safe and effective route and is becoming increasingly popular for children
- Paracetamol
- Entonox
- Nitrous oxide (NO) provides analgesia in sub anaesthetic concentrations
- The patient has to be awake and cooperative to be able to inhale the gas - using a free-flow circuit, NO can be used by children as young as 2 years, although children will need to be 4 or 5 years before they can trigger a demand valve
- Onset of effect is very rapid - it takes 2-3 minutes to reach peak effect and the drug wears off over several minutes
- Most suitable for procedures where short-lived intense analgesia is required e.g. dressing changes, suturing, needle procedures or for pain relief during splinting or transport
- NO may cause nausea, vomiting, euphoria and disinhibition; prolonged exposure to high concentrations can cause bone marrow depression and neuronal degeneration
- NO is contraindicated in children with possible intracranial or intrathoracic air because gas diffusion into confined space may increase pressure
- Topical anaesthesia
- Ametop gel
- Contains tetracaine (amethocaine) base 4%
- Used under an occlusive dressing
- Analgesia is achieved after 30 - 45 mins
- Anaesthesia remains for 4 - 6 hours after removal of gel
- Slight erythema, itching and oedema may occur at site
- Not recommended for children < 1 month
- EMLA cream
- Mixture of lidocaine 2.5% and prilocaine 2.5%
- Used in a similar fashion to Ametop where sensitivity to Ametop occurs
- Analgesia is achieved in around 60 mins
- Ethyl chloride spray
- Works immediately
- Ametop gel
- Local or regional anaesthesia
- Lidocaine 1%
- Used for rapid and intense sensory nerve block
- Onset of action is significant within 2 minutes and effective for up to 2 hours
- Often used with adrenaline to prolong the duration of sensory blockade and to limit toxicity by reducing absorption (should not be used in areas served by an end artery e.g. digit)
- Maximum body dose is 3 mg/kg for plain solutions and 7 mg/kg for solutions that contain adrenaline
- Bupivacaine 0.25 or 0.5%
- Used when longer lasting local anaesthetic is required e.g. femoral nerve block
- L-Bupivacaine used in the same dose is associated with less toxicity
- Onset of action is up to 15 minutes but effects last for up to 8 hours
- Maximum body dose is 2 mg/kg
- Lidocaine 1%
- Procedural sedation
- Ketamine
- Potent dissociative anaesthetic with amnesic and analgesic properties
- Little effect on breathing and protective airway reflexes
- Side effects include hypersalivation, tachycardia and hypertension
- Laryngospasm is a rare complication that can be precipitated by instrumentation of the upper airway
- Emergency phenomenon can be treated with midazolam if necessary
- Midazolam
- Amnesic and sedative drug
- Can be given intravenously, intramuscularly, orally or intranasally
- Onset of action 15 mins after oral administration and recovery after about 1 hour
- May cause respiratory depression or hyperexcitability
- Action can be reversed by flumazenil although this is rarely necessary
- Ketamine
- Analgesia
Algorithm for treatment of acute pain in children in the ED
Initially:
- Assess pain severity
- Use splints/slings/dressings etc.
- Consider other causes of distress e.g. fear of the unfamiliar environment, parental distress, fear of strangers, needle phobia, fear of injury severity etc.
- Consider regional blocks or conscious sedation for procedures
For:
- Mild pain
- Oral/rectal paracetamol 20 mg/kg loading dose, then 15 mg/kg 4 - 6 hourly OR
- Oral ibuprofen 10 mg/kg 6 - 8 hourly
- Moderate pain
- As for mild pain PLUS
- Oral/rectal diclofenac 1 mg/kg 8 hourly (unless already had ibuprofen) AND/OR
- Oral codeine phosphate 1 mg/kg 4 - 6 hourly (over 12 years old only) OR
- Oral morphine 0.2 - 0.5 mg/kg stat
- Severe pain
- Consider entonox as holding measure THEN
- Intranasal diamorphine 0.2 ml (= 0.1 mg/kg) FOLLOWED BY/OR
- IV morphine 0.1 - 0.2 mg/kg infused over 2 - 3 minutes
- Supplemented by oral analgesics
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
