1. EMS providers should receive training in pediatric pain assessment and management to improve care of pediatric patients. Protocols should include pediatric-specific pain management measures. 2. Nonpharmacological strategies like involving child life specialists can help reduce pediatric pain and anxiety. Family presence during procedures can also help. 3. Pain assessment for pediatric patients should begin in the prehospital setting and continue through emergency department discharge with instructions for home pain management.

1. Pain Management for EMSPain Management for EMS
ProvidersProviders

2. Credit to the following sites:Credit to the following sites:
• American College ofAmerican College of
EmergencyEmergency
Physicians is creditedPhysicians is credited
for the informationfor the information
regarding adult painregarding adult pain
management.management.
• http://www.naemsp.org/Documents/CRChttp://www.naemsp.org/Documents/CRC
%20Handouts-%20Handouts-
Atlanta/0041%201.4.3%20PainAtlanta/0041%201.4.3%20Pain
%20Management.pdf%20Management.pdf
• Pediatric PainPediatric Pain
Management perManagement per
American Academy ofAmerican Academy of
Pediatrics, use ofPediatrics, use of
article to quote:article to quote:
• PEDIATRICS Volume 130, Number 5, November
2012
• e1397
• FROM THE AMERICAN ACADEMY OF
PEDIATRICS
• pediatrics.aappublications.org

3. Learning ObjectivesLearning Objectives
• Upon the completion of this programUpon the completion of this program
participants will be able to:participants will be able to:
• Describe current state of EMS pain assessment andDescribe current state of EMS pain assessment and
managementmanagement
• •• Describe most common prehospital uses of analgesiaDescribe most common prehospital uses of analgesia
• •• Describe most common prehospital medicationsDescribe most common prehospital medications

4. Learning ObjectivesLearning Objectives
• •• Describe barriers to effective analgesia and strategiesDescribe barriers to effective analgesia and strategies
to overcome barriersto overcome barriers
• •• Describe important differences between adult andDescribe important differences between adult and
pediatric pain managementpediatric pain management
• •• Describe emerging issues in prehospital painDescribe emerging issues in prehospital pain
managementmanagement

5. Pain IntroductionPain Introduction
• Pain is among most common requests forPain is among most common requests for
EMSEMS
• •• Pain is associated with increasedPain is associated with increased
morbidity and potentially mortalitymorbidity and potentially mortality
• •• Wide variation in EMS assessment andWide variation in EMS assessment and
management of painmanagement of pain

6. Pain IntroductionPain Introduction
• •• Research shows under treatment /Research shows under treatment /
oligoanalgesia is commonoligoanalgesia is common
• •• Significant barriers to more effectiveSignificant barriers to more effective
performance identified in recurrentperformance identified in recurrent
studies.studies.

7. Conditions for EMS PainConditions for EMS Pain
ManagementManagement
• Most common:
• – Cardiac / Chest, Isolated extremity,Cardiac / Chest, Isolated extremity,
BurnsBurns
• •• Less common but growingLess common but growing
rationale:rationale:
CA complications, Rheumatoid syndromes,CA complications, Rheumatoid syndromes,
Sickle cellSickle cell

8. Conditions for EMS PainConditions for EMS Pain
ManagementManagement
• Controversial:Controversial:
• –– Trauma extrication, multitrauma w / woTrauma extrication, multitrauma w / wo
TBI, nondifferentiated abdominal,TBI, nondifferentiated abdominal,
Pregnancy/ Labor, Patients with painPregnancy/ Labor, Patients with pain
related condition using other prescribed orrelated condition using other prescribed or
nonprescribed medicationsnonprescribed medications

9. EMS FormularyEMS Formulary
• Non‐pharmacologic management generallyNon‐pharmacologic management generally
needs more attentionneeds more attention
• •• MS remains most common injectableMS remains most common injectable
• •• Fentanyl increasing replacement of MS due toFentanyl increasing replacement of MS due to
concerns about untoward side effects.concerns about untoward side effects.
• •• Other common: Nalbuphine, Meperidine (goingOther common: Nalbuphine, Meperidine (going
out)out)
• •• Less common: NO/ “Nitronox”, Ketamine,Less common: NO/ “Nitronox”, Ketamine,
DilaudadDilaudad

10. Individual Barriers to PainIndividual Barriers to Pain
ManagementManagement
• Poor pain assessment skills and reluctance to use inPoor pain assessment skills and reluctance to use in
absence of significant objective signsabsence of significant objective signs
• •• Excessive concerns over “malingerers” and drugExcessive concerns over “malingerers” and drug
seeking behaviorseeking behavior
• •• Unclear endpoints and ambivalence around targetsUnclear endpoints and ambivalence around targets
• •• Fear of masking and aggressive dosingFear of masking and aggressive dosing
• •• Limited education on pediatric and geriatricLimited education on pediatric and geriatric

11. Structural Barriers to Pain ManagementStructural Barriers to Pain Management
• Requirements for direct orders (on‐line)Requirements for direct orders (on‐line)
• •• Dosing regimen’s (initial doses are limited) andDosing regimen’s (initial doses are limited) and
limited total amount carried on EMS unitslimited total amount carried on EMS units
• •• Pediatric assessment support tools, ie. weight basedPediatric assessment support tools, ie. weight based
on tapes and injectables as primary analgesia.on tapes and injectables as primary analgesia.
• ••Increased paperwork post call with increasedIncreased paperwork post call with increased
turnaround timesturnaround times

12. Strategies to Improve Pain ManagementStrategies to Improve Pain Management
• Studies indicate targeted education improvesStudies indicate targeted education improves
paramedic confidence and performanceparamedic confidence and performance
• •• Required use of pain assessment andRequired use of pain assessment and
documentationdocumentation
• •• Using standing orders vs. on‐line ordersUsing standing orders vs. on‐line orders
• •• Consideration of other non‐injectables mayConsideration of other non‐injectables may
improve analgesia performance especially forimprove analgesia performance especially for

13. ““FACES” Pain ScaleFACES” Pain Scale

14. Emerging IssuesEmerging Issues
• Shortages of injectables are affecting EMS and ED medicationShortages of injectables are affecting EMS and ED medication
• AvailabilityAvailability
• •• Unpredictable shortages leading to rapid changes in formularyUnpredictable shortages leading to rapid changes in formulary
• and concentrations.and concentrations.
• •• Changes in formulary and concentrations increase risk ofChanges in formulary and concentrations increase risk of
• medication errors to patients and providersmedication errors to patients and providers
• •• DEA control requirements are further exacerbating shortagesDEA control requirements are further exacerbating shortages
• •• Provider diversionProvider diversion
• •• Unclear use of analgesia agents for pharmacologically assistedUnclear use of analgesia agents for pharmacologically assisted

15. Take‐Home PointsTake‐Home Points
• Improvements to paramedic education on pain physiology needed toImprovements to paramedic education on pain physiology needed to
improve prehospital pain managementimprove prehospital pain management
• •• Critical populations for improvement are pediatrics, geriatrics, and ethnicCritical populations for improvement are pediatrics, geriatrics, and ethnic
Targeted education and requiring documented pain scoring improve painTargeted education and requiring documented pain scoring improve pain
management performancemanagement performance
•• Changing paramedic education to classes vs. individual medications isChanging paramedic education to classes vs. individual medications is
needed especially due to recurrent shortages and changes in formularyneeded especially due to recurrent shortages and changes in formulary
Improvements needed in non‐pharmacological interventions and potentialImprovements needed in non‐pharmacological interventions and potential
non‐injectable routes of administrationnon‐injectable routes of administration
• •• Standing orders improve performance and time to analgesiaStanding orders improve performance and time to analgesia
• •• Medical Directors need to assess system and practitioner performance.Medical Directors need to assess system and practitioner performance.
• Templates from current studies and NAEMSP Position Papers are useful tools in this effort.Templates from current studies and NAEMSP Position Papers are useful tools in this effort.
• • “• “pain is inevitable, suffering is optional” anonymouspain is inevitable, suffering is optional” anonymous

16. Credit to :Credit to :

17. Pediatric Pain Management perPediatric Pain Management per
American Academy ofAmerican Academy of
PediatricsPediatrics
• The learning objectives for pediatrics areThe learning objectives for pediatrics are
similar to adult pain management, with thesimilar to adult pain management, with the
exception that children often have anxietyexception that children often have anxiety
of the unknown mixed with the actualof the unknown mixed with the actual
source of pain. The following slides aresource of pain. The following slides are
sourced from sites noted.sourced from sites noted.

18. • It is clear that there is a relationship
between anxiety and perceived pain in
children and adults.
• The creation of an appropriate
environment is essential to minimize the
pain and distress of a childs ED visit.
• This is also true of EMS providers,
keeping a child’s caregiver’s or a familiar
toy or blanket for comfort.

19. Pain Assessment in the ED
• The Joint Commission standards include
mandatory pain assessments for all
hospital patients.
• Pain is, by nature, a subjective
experienceand is influenced by social,
psychological, and experiential factors.

20. Chronic Pain—all agesChronic Pain—all ages
• For example, patients who experience
chronic pain may not report the same pain
level or exhibit the same facial cues and
vocalizations as those who are new to
the pain experience.

21. Pain AssessmentPain Assessment
• Pain assessment, which is obviously the
• first step toward appropriate treatment,
can, therefore, be more complex than just
obtaining a single pain score; it is also
essential to pay attention to changes in
pain scores in response to treatment.
• PEDIATRICS Volume 130, Number 5, November 2012

22. Does the Appropriate Use of Analgesics MakeDoes the Appropriate Use of Analgesics Make
Evaluation More Difficult?Evaluation More Difficult?
There is no evidence that pain
management masks symptoms or
clouds mental status, preventing
adequate assessment and diagnosis.
For patients with abdominal pain,
several adult studies have shown that
pain medications such as morphine can
be used without affecting diagnostic
accuracy.

23. Pediatric Pain ManagementPediatric Pain Management
• Pediatric studies have demonstrated
similar findings.

24. • Clinical experience suggests that the use
of pain medication makes children more
comfortable and makes the examination of
the patient’s abdomen and diagnostic
testing (such as ultrasonography) easier,
thus aiding in diagnosis.

25. • The use of sedative hypnotic medication
may be required to reduce pain and distress
for children undergoing procedures in the
ED.
• Unfortunately, pain and anxiety are often
difficult to differentiate in infants and
toddlers and even in school-aged children.

26. • Although many procedures can be
performed relatively painlessly with the
use of a topical or local anesthetic, this
does not obviate the use of pharmacologic
agents to decrease the anxiety and stress
in children undergoing procedures in the
ED, especially when the child needs to
remain still to ensure the success of the
procedure.

27. • When the procedure is expected to be
painful, the agents used should have
analgesic properties as well. Emergency
physicians are increasingly using short-
acting medications such as propofol,
alone or in combination with ketamine, for
procedural sedation in children.

28. Pain Considerations for Children With
Developmental Disabilities
• Children with developmental disabilities,
particularly those with severe neurologic
involvement, provide additional challenges
to parents and EMS and ED personnel in
management of acute pain and its
associated anxiety.

29. Pain Considerations for Children With
Developmental Disabilities
• For many children, previous painful experiences
in similar settings add to stress of the acute
incident. Learning about the child’s anticipated
response and previous experiences from
parents, primary care physicians, and specialists
informs the emergency physician and staff of
useful supportive technique.

30. Caregiver InvolvementCaregiver Involvement
• Parental understanding and awareness of
subtle indirect behaviors or emotional
shifts are often critical adjuncts in the
assessment process of the child’s sense
of comfort and well-being.

31. CONCLUSIONS
• Management of a child’s distress during
illness or after an injury is an important yet
complex aspect of emergency medical
care for children. Physicians and
prehospital EMS providers should be
aware of all the available analgesic and
sedative options.

32. • Adequate pain assessment is essential for
pain relief and should begin on entry into the
EMS and continue through discharge of
the child from the ED.

33. Implementation
• A systematic approach to pain
management in the EMS requires an
implementation strategy, promoted and
advocated by leadership, that includes
the following:
• (1) a comprehensive evaluation of current
pain and distress management practices;

34. • ; (2) an educational and credentialing program
regarding pain assessment and management
techniques for all clinical staff, preferably
overseen by a hospital wide sedation committee
;(3)development of protocols to allow the universal
and efficient application
of pain management strategies and medications;
and
(4) a quality improvement process to evaluate the
ongoing success of the program.

35. EMS
• agencies should establish policies and
protocols that make available pertinent
provider education and ensure quality
improvement processes are in place for
pediatric pain management protocols
appropriate for their practice setting.

36. SUMMARY OF KEY POINTS
• 1. Training and education in pediatric pain
assessment and management should be
provided to all participants in the EMS for
children; EMS medical directors should
• formally include pediatric pain
management measures within the
protocols provided to EMS providers.

37. • 2. Incorporation of child life specialists
and others trained in nonpharmacologic
stress reduction can alleviate the anxiety
and perceived pain related to pediatric
procedures.

38. • 3. Family presence during painful
procedures can be a viable and useful
practice in the acute care setting.

39. • 4. Pain assessment for children should
begin at admission to EMS, including
prehospital management, and continue
until discharge from the ED. When
discharged, patients should receive
detailed instructions regarding analgesic
administration

40. • 5. Administration of analgesics and
anesthetics should be painless or as pain
free as possible.
• 6. Neonates and young infants should
receive adequate pain prophylaxis for
procedures and pain relief as appropriate.

41. • 7. Administration of pain medication has
been demonstrated to preserve the ability
to assess patients with abdominal pain
and should not be withheld.
• 8. Sedation or dissociative anesthesia
should be provided appropriately for
patients undergoing painful or stressful
procedures in the ED.

42. • 9. Pain management and sedation, including deep sedation and dissociative
anesthesia, are fully within the monitoring and management capabilities of
appropriately trained emergency medicine and pediatric
emergency medicine physicians.
• Each emergency department that provides sedation and analgesia to
children should include sedation competencies in recredentialing
procedures and develop protocols, policies, and quality improvement
programs as part of the systematic approach to pain management in the
EMS
PEDIATRICS Volume 130, Number 5, November 2012
e1397

43. • Anxiety relief and pain control using
pharmacological agents are critical
elements to improving outcome,
particularly from the patient's point of view.
Careful assessment of the patient and
titration of these medications can improve
outcomes. In addition to providing pain
control, many of the opioids have
significant cardiac benefits.

44. Patient DocumentationPatient Documentation
• The EMS patient record should document
any clinical or technical problems during
administration of these medications, along
with any significant patient events such as
nausea and vomiting, respiratory distress,
vagal or anaphylactic reaction or
diaphoresis, as well as any intervention
taken by the paramedic.

45. Patient MonitoringPatient Monitoring
• Monitoring of patients undergoing
sedation and pain control, particularly
where the patient is at risk for respiratory,
ventilatory, oxygenation or hemodynamic
changes from the influence of
pharmacological agents, which suppress
respiration, is vital to the patient's safety.

46. • Many such clinical situations occur in
settings where standard monitoring
equipment is not available or access to the
patient and equipment is limited.
• Monitoring should not be limited to
intermittent manual observation. Among
the noninvasive methods of patient
monitoring, several parameters can
provide continuous information on the
respiratory effort and subsequent
ventilation and oxygenation status of the
patient.

47. • The paramedics' ability to use, interpret
and act upon the data derived from the
patient assessment and monitoring
technology will help ensure a positive
outcome for the patient. Promoting patient
comfort and reducing or eliminating pain
are the responsibilities of all prehospital
clinicians, while at the same time ensuring
patient safety.