Background
Pain is commonly under-recognised, under-treated and treatment may be delayed. Drug choice and dosage may also cause problems due to unfamiliarity. 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 Emergency Department and finish with ensuring adequate analgesia at, and if appropriate, beyond discharge. In treating pain, pay attention to the other factors distressing the child such as fear of the unfamiliar environment and people, parental distress, people in uniforms, needle avoidance, fear of injury severity etc.
Principles of pain management
- Ask about pain regularly and Assess systematically
- Believe the patient and family if they report pain
- Choose pain control options appropriate for patient and level of pain
- Deliver interventions timely, logically and coordinated
- Empower patients and their family. Enable them to control their pain to the greatest extent possible
Assessment of acute pain in children in the ED
- Pain assessment should be considered as the 5th vital sign
- Performed at triage and at regular intervals
- Take account of age and cognitive understanding of the child
- The assessment of pain includes a careful history and physical examination
- Pain Assessment Tools
- Self reporting (subjective pain assessment) - reliable in older, verbal children, e.g. Wong Baker FACES, Visual Analogue Scale (VAS), Numeric pain scales, Pain Ruler
- Pain rating by parent/nurse/carers (objective pain assessment), e.g. FLACC, Alder Hey Triage Pain Score, Manchester Pain Ladder
- It is important to distinguish other causes of distress in children e.g. emotional, parental separation, thirst, hunger, etc
Children < 5 years - FLACC
Children 5-7 years Wong Baker FACES
Children >7 years - use VAS (scale 0-10[10 worse pain ever])
FLACC scale <5 years
| 0 | 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| Face | No particular expression or smile | Occasional grimace or frown, withdrawn, disinterested | Frequent to constant quivering chin, clenched jaw |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, distractable | Difficult to console or comfort |
Wong Baker FACES (5-7yo)
| No Pain | Mild Pain | Moderate Pain | Severe Pain | |
|---|---|---|---|---|
| Faces pain score |  |
 |
 |
 |
| 0 | 1 - 3 | 4 - 6 | 7 - 10 | |
| Behaviour | Normal activity No ↓ movement Happy |
Rubbing affected area ↓ movement Neutral expression Able to play / talk normally |
Protective of affected area ↓ movement / quiet Complaining of pain Consolable crying Grimaces when affected part moved / touched |
No movement or defensive of affected part Looking frightened Very quiet Restless, unsettled Complaining of lots of pain Inconsolable crying |
| Example | Bump on head | Abrasion / Small laceration Sprain ankle / knee # fingers / clavicle Sore throat |
Small burn / scald Finger tip injury # forearm / elbow / ankle |
Appendicitis Large burn # long bone / dislocation Sickle crisis |
Pain Ruler
- Once the category has been established, appropriate analgesia may be prescribed according to the flow chart
- In all cases it is important to think of using other non-pharmacological techniques to achieve analgesia.
- These may include play and distraction or other measures such as applying a dressing or immobilising a limb
- Following reassessment if analgesia is still found to be inadequate, stronger analgesics should be used along with the use of non-pharmacological measures
- Points to remember:
- Children who fall into the moderate / severe categories should also be given basic analgesia
- Most children can and are able to use Entonox, remember this may be a valuable source of analgesia whilst waiting for oral analgesia to work
How to treat pain
Non-Pharmacological
- Psychological strategies: involving parents, cuddles, child-friendly environment, and explanation with reassurance all help build trust.
- Also, distraction with toys, blowing bubbles, reading, or story-telling using superhero or magical imagery to make the pain go away
- Non-pharmacological adjuncts such as limb immobilisation, dressings for burns
Pharmacological
- Pharmacological agents, via a variety of routes: see attached algorithm.
- Use TAC in preference to EMLA for topical anaesthesia [BestBets]
- For superficial wounds, topical anaesthesia should be used in preference to Lignocaine infiltration [BestBets]
- Also local or regional anaesthesia are useful (e.g. femoral and auricular blocks)
- For procedures, departments may consider conscious sedation using Ketamine (IV / IM) (more on Ketamine sedation)
- PO/IV/IN options include, Non-opioid, Opioid (including intra-nasal Fentanyl) and inhaled (N2O)
Contra-indications
Ibuprofen / Diclofenac: avoid if previous reactions to NSAIDs or in moderate or severe asthmatics.
Intravenous morphine: use with caution if risk of depression of airway, breathing or circulation.
Oral and parenteral analgesia
| Drug | Dose per Kg | Frequency |
|---|---|---|
| Paracetamol | 15mg/Kg orally Up to 30mg/Kg PR |
4-6 Hrly Max 60mg/Kg/day |
| Ibuprofen (beware in asthmatics) |
10mg/Kg orally | QDS to max 20mg/Kg/24 hrs |
| Diclofenac | 1mg/Kg PO or PR | TDS to max 3mg/Kg/day or 150mg daily |
| Codeine | 1mg/Kg orally to max 30mg each dose | 4 - 6 Hrly |
| Morphine | 0.1mg/Kg IV 200 mcrg/Kg PO in <1yo 400 mcrg/Kg PO in 1-2yo |
PRN (Reverse with Naloxone 10mcg/Kg then 100mcg/Kg) |
| Sucrose | >1500g child:0.2-0.25ml of 24% Sucrose (Sweetease) dropped on the anterior tongue in divided doses 2 minutes before procedure, continue during procedure for a total dose of 2mls (action lasts approximately five minutes) | Maximum of 4 doses in 24 hours. More on Sucrose |
| Fentanyl Intranasal | IN 1.5 mrcg/kg/dose (use 50 mcrg/mL soln.). Dosing below. | |
| Weight | IN Fentanyl Dose (1.5mcg/kg) | Volume(ml) |
|---|---|---|
| 10 | 15 | 0.3 |
| 11 | 15 | 0.3 |
| 12 | 20 | 0.4 |
| 13 | 20 | 0.4 |
| 14 | 20 | 0.4 |
| 15 | 24 | 0.5 |
| 16 | 24 | 0.5 |
| 17 | 24 | 0.5 |
| 18-24 | 30 | 0.6 |
| 25-29 | 40 | 0.8 |
| 30-34 | 45 | 0.9 |
| 35-39 | 55 | 1.1 |
| 40-44 | 60 | 1.2 |
| 45-49 | 70 | 1.4 |
| 50-54 | 75 | 1.5 |
| 55-59 | 85 | 1.7 |
| 60-64 | 90 | 1.8 |
| 65-69 | 100 | 2 |
Local anaesthetics
Ametop
Can be used in children over 1 month old
Leave in situ for 30 mins for venepuncture
Remove after 1 hour
Lasts 4 - 6 hours after removal
Do not use on mucous membranes
Emla
Children over 1 year of age
Should be left in situ for minimum 1 hour
After 2 hours will provide anaesthesia to 6 mm depth
Lignocaine 1%
Max 3mg/Kg
Adrenaline & cocaine gel
1ml of gel per 1cm of wound
To max 4mls
Not on mucous membranes or abrasions
Controlled drug
- Use TAC in preference to EMLA for topical anaesthesia [BestBets]
- For superficial wounds, topical anaesthesia should be used in preference to Lignocaine infiltration [BestBets]
Links
- IAEM Clinical Guideline - Analgesia in Children)
- Bier's Block Regional Analgesia
- Clinical Effectiveness Committee. January 2002
- Emergency Triage. BMJ Publishing Group, 1997
- McGrath PJ et al, CHEOPS: A behavioural scale for rating postoperative pain in children. Advances in Pain Research and Therapy, vol 9, Ed. Fields, Raven Press, 1985
- Wong-Baker Faces Pain Scale. Adapted from Whaley L, Wong DL. Nursing care of infants and children. 3rd ed. St Louis: The CV Mosby Company, 1987
- Advanced Paediatric Life Support, 3rd ed. BMJ Publishing Group, 2001