Paediatric Pain and Sedation from #EuSEM15

Editor's Notes

1. • Pain is more than nociception
2. • Be creative, thoughtful and flexible with drug-based approach: BE PREPARED
3. • Address the wider factors affecting pain response
4. Lots of talks at EuSEM about paediatric pain - why? Why are we talking about pain?
5. Common presentation – about 50% of attendances involve pain. Back in 1997 Petrack’s paper in Pediatrics suggested children in ED in pain receive analgesia less than adults and that difference is more profound where adult and paediatric EDs are not geographically separate.
6. But that was 18y ago. In the UK we have standards: analgesia in severe pain within 20mins, re-evaluate at 60mins. And we audit this regularly - we’ve audited it 6 times, so we must be pretty good at it by now, right?
7. Something we do badly (RCEM audit) – 2011-2012 (6th iteration) higher proportion receiving pre-hospital analgesia but we are still barely managing to provide analgesia in moderate to severe pain Nationally, only 5% of all audited children received adequate pain relief before arrival in the ED, 43% within 20 minutes of arrival, 57% within 30 minutes and 72% within 60 minutes of arrival. Even in severe pain only 53% received analgesia within 20mins of arrival in ED. And if we are actually reassessing we are not recording that in a way which lends itself to this audit.
8. Pain is hard to measure. Many children are too young to give a numerical score - and many adults struggle with this too. There are other scales we can use but with something so subjective, it’s difficult to find a valid and reliable measure and I wonder if that’s why sometimes we don't even try.
9. Why is pain hard to measure? Not easy – multifactorial Pain and distress Pain is so much more than nociception and pain pathways More complex than tissue damage causing neuronal firing - who has a tattoo? Who has more than one tattoo? These people have chosen pain. Not all pain is unpleasant, so much of our pain response is determined by factors other than the extent of tissue damage.
10. • Pain is more than nociception
11. But… Pain affects our clinical assessment. In our search for diagnoses we may miss the point. We should address the reason people come to the ED - yes, they want to know why it hurts, but they’ve come because it hurts, so let’s help with that Maybe we can rethink the way we approach children in pain to give them a better ED experience
12. Pain in kids Complicated by negative emotions surrounding pain, injury and hospital Understand a little developmentally
13. toddlers transition from stranger anxiety to separation anxiety – we make their worst nightmares come true
14. Neonates we thought didn’t feel pain – used to intubate without drugs however now we recognise that pain alters clinical outcomes, brain development and subsequent behaviour. Studies show neonates who experience pain develop increased pain sensitivity and hyperalgesia, and is associated with changes in behavioural stress responses, ultimately leading to psychosomatic pain and psychiatric disorders in later life.
15. However, inflicting pain to relieve pain - if you want to give IV/IM meds - is not something that most children can rationalise. So let’s think flexibly, creatively about managing pain.
16. For injury we have a number of options. We can start simply. We can give oral paracetamol and ibuprofen. In the UK we no longer give codeine to under 12s.
17. We can utilise local anaesthetic – regional blocks, like femoral nerve blocks for femoral shaft fractures can work brilliantly.
18. We are probably still underusing the intranasal route; diamorphine use is well established and well tolerated but fentanyl and ketamine are other intranasal options. A study (small admittedly) published in the American Journal of EM this week demonstrated how introduction of a protocol for intranasal fentanyl could reduce time to administration of analgesia for children in pain.
19. Don’t underestimate the value of splinting and immobilising bony injuries – this can be incredibly helpful. Think sensibly about this: if a child obviously has a fracture without XR then they need an XR – but they’re also going to need an intervention, so why not treat the patient first?
20. For wounds we have great success in Manchester using LAT gel, TAC gel exists as an alternative – apply to wound, leave 45mins and usually provides sufficient anaesthesia for cleaning and closure. Generally rule of Jenner – if child lets you put it on, they’ll let you complete what’s required. Can supplement with additional lidocaine if required.
21. Free flowing entonox (50% O2:N2O) is a great adjunct. Require scavenging in dept but use valve with reservoir bag – MAC of 105% means it won’t produce full anaesthesia unless in hyperbaric conditions (ED pressure is high but not hyperbaric…yet)
22. Children with illnesses can have pain too and similar principles apply. Start simple, don’t be afraid to work up. Anticipate your patient’s needs (so put the ametop on in anticipation that things won’t feel better and don’t be frightened of IV opiates and opioids – if the child needs them, they need them. Titrate slowly and you’ll be ok)
23. • Be creative, thoughtful and flexible with drug-based approach: BE PREPARED
24. Pain associated with procedures presents a slightly different set of challenges. There are two key questions we need to ask before we embark on this journey in the ED
25. 1. Is this necessary? Is there genuine benefit in performing this procedure right now in the ED?
26. 2. Is the ED the most appropriate place? – the answer to this might be multifactorial and include things like staffing capability, skill mix, ED capacity, availability of equipment
27. Realistically you are going to invest far more time in preparation for the procedure than in doing it For older children, calm conversations about what is necessary and why and how it is going to happen. It may be helpful to outline or write down the steps involved, to demonstrate equipment or simulate practice.
28. In terms of full procedural sedation, don’t think of sedation in isolation without analgesia. Local, regional or topical anaesthesia may be used in conjunction with sedation to good effect.
29. Don’t jump straight in. Stop, think, invest time - it will be worth it. Anticipate the need for intravenous access, apply topical anaesthesia.
30. • Address the wider factors affecting pain response
31. Preparation is the key to sedation success and is, I would argue, more important than the medications you choose. Use experienced nurses to help – they are often expert at holding and positioning children
32. But not everything to do with pain is about drugs Pain has significant psychological, behavioural, emotional and cultural components. These can be brought into play to modify and dampen pain responses
33. Communication – your voice, your demeanour, your words – can determine an atmosphere which can escalate or de-escalate distress.
34. Parents – your greatest ally. Have them on your team. Pep talk them. They need to know exactly what you expect of them. Reward them afterwards
35. Play therapists exist for this role – they are the masters! We don’t make enough use of them, involve them early, especially for children for whom procedures are anticipated to be difficult (eg autistic spectrum disorder)
36. Think about atmosphere – use music, lighting. Music is good for reducing anxiety during procedures (CT scan paper) and also when using ketamine, to reduce emergency phenomena
37. Use adjuncts which focus on distracting physical sensations, like the buzzy bee: poor evidence base but harms likely few and may work by distraction. Consider warmth (especially for abdominal pain)
38. Neonates: Swaddling – an ancient practice for neonates with evidence for soothing pain, non-nutritive sucking (dummies, sucrose). Both are recommended in combination with sucking providing quicker resolution of crying and normality of vital signs after painful stimulus and swaddling showing a lesser rebound effect after removal
39. • Pain is more than nociception
40. • Be creative, thoughtful and flexible with drug-based approach: BE PREPARED
41. • Address the wider factors affecting pain response
42. Please be kind to children – it is in your interest to make things run smoothly. You are investing in future ED attendances, not just in your patient’s childhood but in their experiences into adulthood too. Thank you!