AUTHORS
Chisom A. Agbim, MD, Pediatrics Resident, Lucile Packard Children's Hospital Stanford, Palo Alto, CA
N. Ewen Wang, MD, Professor, Emergency Medicine, Associate Director, Pediatric Emergency Medicine, Stanford University Medical School, Stanford, CA
PEER REVIEWER
John Cheng, MD, Pediatric Emergency Medicine Physician, Pediatric Emergency Medicine Associates, LLC, Children's Healthcare of Atlanta, Wellstar Health System, Atlanta, GA
Pain management in the pediatric population has long been a focus of healthcare providers; nevertheless, gaps in providing adequate and timely pain management remain an area of concern in emergency departments (ED). This article will provide guidance for the recognition and successful management of pediatric pain in the ED setting. The authors first present definitions of pain and discuss the assessment of pain in a child, as well as common barriers to appropriate pediatric pain management in the ED. Then, the article will focus on the different aspects of pain and techniques of managing discomfort, including: anxiolysis, non-pharmacological strategies, topical medications, oral analgesics, parenteral medications, discharge medications, and misconceptions and facts about opioid analgesics. Pain control in conjunction with procedural sedation is beyond the scope of this article.
— Ann M. Dietrich, MD, FAAP, FACEP, Editor
Definition and Background
Pain is defined as an unpleasant somatic or visceral sensation associated with actual, potential, or perceived tissue damage.1 Pain is a complex and unique experience for all individuals. It can be affected by factors including one’s own anxiety or surrounding environment. Children suffer pain in the same way as adults; however, exposure to painful events in early childhood can have a direct effect on future neurobiological development. Studies have shown that early exposure to painful experiences and undertreated pain at crucial developmental periods can cause changes in the activity and structure of the central nervous system and cause long-term effects in a child’s perception of pain at later stages of childhood.2,3 In some instances, chronic pain originates from one or more acutely painful episodes early on that continues to resonate even throughout adulthood.2 The goal of pediatric pain management is to prevent avoidable pain and to eliminate pain in the most timely, efficient manner possible.
It has been well documented that pain is widely undertreated, especially in the pediatric population.4,5,6,7 In 2001, the U.S. Congress renewed its focus on the recognition and treatment of pain. With this came an emphasis on adequate and timely pain management. Shortly afterward, the Joint Commission on Accreditation of Healthcare Organizations established standards for pain assessment and management in response to the public outrage about the widespread problem of the undertreatment of pain.8 This included a mandate that methods used to assess pain are consistent with a patient’s age, condition, and ability to understand. Although several advances have been made in improving pediatric pain management since the publication of these standards, several gaps still exist. Children continue to receive less analgesia in general EDs than adults, and fever is treated more promptly than pain in pediatric EDs.9,10 Even in the pediatric population, children younger than 2 years of age receive disproportionately less analgesia in the ED than school-age children, despite having obviously painful conditions.10
The barriers to identifying pain and delivering timely, appropriate, and safe analgesia for pediatric patients are multifactorial. Seventy percent of all patients presenting to the ED are in some pain and/or require a painful procedure.11 Pediatric and adolescent patients account for one-third of all patients seen in general EDs.11 Although pain assessment is required for all hospitals and all practicing professionals receive pain assessment training, there continue to be gaps in actual pain management. Common barriers to optimal pain management in general EDs include patient volume, staffing issues, failure to include non-pharmacologic strategies in the treatment of pain, generally inaccurate pain assessments, insufficient pain medications available at triage, and difficulty with timely reassessment of pain in a busy ED environment.12 Some barriers that are more common to children presenting to a general ED include provider selection of inappropriate pain scales, the patient’s own inaccuracy in using pain scales, the lack of awareness that pediatric pain continues to be undertreated, provider unfamiliarity with new pain management techniques, and medication dosing errors in pediatric populations (although less so with the emergence of electronic orders in the electronic medical record system).12
Approach to Pain Management in the ED
Timing is a major component of adequate assessment and treatment in the pediatric population. Upon initial triage, providers should implement an appropriate pain scale based on a child’s age and cognitive ability.
Important Aspects to Consider When Assessing Pain
Management of pain in the pediatric population begins with an accurate assessment. Although most adults can quantify pain with numeric scales, pain assessment in the pediatric population is more complex. A child’s ability to express pain can be influenced by age, cognitive development, gender, and cultural context. Pain assessment also is greatly influenced by the child’s level of anxiety, stress, and fear, which often is exacerbated by the chaotic ED environment.13 Additionally, as with adults, description and expression of pain also can be affected by culture.
Age and developmental variation are particularly important in the pediatric population in relation to pain. Children younger than 18 months are able to indicate that they are in pain by crying or simple expressions but cannot conceptualize or verbalize different levels of pain intensity.14 By 18 months old, a child can verbalize the fact that something hurts, localize the pain, and know that their pain may be alleviated.14 Between 2 and 4 years of age, children are better able to process the external aspects of objects and situations, leading to more elaborate descriptions of pain attributed to external causes.15,16 For example, children in this age range can identify and articulate an external cause of pain such as “the ball hit me and it hurt.” At 5 years of age, children can describe discomfort and define pain intensity; and by 6 years of age, they can clearly differentiate between levels of pain intensity.17 Children from 7 to 10 years of age generally are able to explain their pain and why it hurts.14 Adolescents are able to explain pain in a more abstract manner that includes both physical and emotional aspects.16
Normal fear and anxiety in children also follow a clear developmental pattern.18 For centuries, psychologists have described this pattern as fear of the natural environment and imaginary creatures in early preschool years, fear of physical danger in middle childhood, and fear of death and illness during adolescence.19,20 These aspects must be addressed routinely during pain assessment and should be used to individualize pain management for each patient’s needs.
Simple Strategies to Decrease a Child’s Anxiety in the ED
The expectation and presence of pain increases anxiety and pain perception.21 Anxiety is often manifested as irritability, resistance, and non-cooperation. To decrease unease, providers should use environmental and cognitive-behavioral strategies as applicable. These strategies help to distract and, therefore, decrease the child’s level of anxiety.
To decrease environmental stressors, children should be placed in individual child-friendly rooms, away from the noise and chaos of the ED. Simple techniques, including distraction (bubbles, toys, books, and visual aids), deep breathing techniques, and guided imagery can be very effective with young children.22,23 In addition, providing education, teaching coping techniques, and explaining procedures and treatment flow during the visit should be done by trained ED staff and child life specialists, when possible. Providers should explain procedures using age-appropriate language and refrain from making false promises, such as telling a patient that he or she will not experience any pain when the intervention has a possibility of being painful. Allowing a parent to be present for procedures as permitted also can decrease stress and anxiety. Parents also play a fundamental role in joint decision-making when creating pain management plans for their children.
Assessment of Pain
In the pediatric population, pain assessment most often is achieved by two means — observational/behavioral scales and self-reporting. (See Table 1.) Observational/behavioral scales rely on a provider’s interpretation of crying, groaning, facial expression, and posturing. These scales are reserved for patients who are too young to verbalize their pain and for cognitively impaired patients. Self-reporting relies on patients to verbalize their feelings and understand their pain on a continuum. Self-reporting is considered the gold standard for pain reporting because pain is primarily an internal experience, and self-reporting offers a window on the subjective aspects.17,24 Observational scales can be used as a complement or substitute when self-reporting is unavailable or in doubt.25 Physiologic measures (i.e., blood pressure and heart rate) are not effective for estimating pain because of variation by age and because these parameters are being affected by factors other than pain, such as fear, anxiety, and stress.13 It is important to note that while anxiety can increase pain perception, it is not accounted for separately in pain scales.22 Scales specifically for pain and for anxiety have been discussed in the literature; however, they are beyond the scope of this article.
Table 1. Examples of Common Pain Scales Used in the Emergency Department* 26,27,28 |
||
Observational Scales |
||
|
Tool |
Age |
Descriptions |
|
Revised Face, Leg, Activity, Cry, Consolability (r-FLACC) |
Newborn to 16 years |
Rates patients on a scale of 0-2 for each of the following categories Face, Legs, Activity, Cry, Consolability. Totals are added from each category for an overall scale of 0-10. Scores are interpreted as: 0 = Relaxed and comfortable 1-3 = Mild discomfort 4-6 = Moderate pain 7-10 = Severe pain or discomfort or both |
|
Nursing Assessment of Pain Intensity (NAPI) |
Newborn to 16 years** |
Rates pain in three different domains, including: bodily movement (0-2), facial expression (0-3), and touching (0-2), where 0 = no pain and 7 = worst pain. |
|
Self-Reporting Scales |
||
|
Tool |
Age |
Descriptions |
|
FACES Pain Scale Revised |
3-8 years |
A linear visual analog scale that uses expressive faces labeled (0, 2, 4, 6, 8, and 10) to demonstrate one’s pain intensity. The faces are displayed linearly with increasing levels of expression where "0" equals "no pain" and "10" equals "very much pain." |
|
Wong-Baker Pain Scale-Revised |
3-8 years |
A linear visual analog scale featuring illustrated character faces of increasing expressions of pain. Faces are labeled: 0 = no hurt 2 = hurts a little bit 4 = hurts a little more 6 = hurts even more 8 = hurts a whole lot 10 = hurts worst |
|
Horizontal Numeric Pain Rating Scale |
8-11 years |
A type of visual analog scale featuring a segmented horizontal line that usually is displayed as a gradient that is meant to reflect one’s level of pain. The scale is segmented into 11 even integrals from 0-10. The following cut points have been recommended: 0 = no pain, 5 = moderate pain, and 10 = worst pain imaginable. |
|
Verbal Numeric Scale |
11 years to adult |
A verbal self-reporting scale that is used to assess one’s level of pain. The scale is quantified into 11 integers with 0 indicating no pain and 10 indicating the worst pain. Similar to the Numeric Pain Rating Scale; however, there is no visual component |
|
*Note the use of certain pain scales is largely institution dependent. To date there is no set standard pain scale or scales that are specific for ED use. **May be used for patients with cognitive disabilities SOURCE: Author adapted. |
||
Pain Assessment Scales Typically Used in the ED
No single pain scale has met criteria for accuracy and validity for all pediatric populations. As a result, there is no universal protocol for pediatric pain assessment in the ED. There are many validated, age-based pain scales that can be applied to a fast-paced ED setting; however, the frequency with which a pain assessment tool is used varies depending on each institution’s preferences.
The most common observational scale used in U.S. EDs is the Revised-Face Legs Activity Cry Consolability (r-FLACC) scale, which has received the highest clinical utility score. In nonverbal children, the Nursing Assessment of Pain Intensity (NAPI) was rated highly among clinicians for clinical utility compared with other pain scales for cognitively delayed patients.29
For younger children, visual analog pain scales are used to qualify pain and translate it into a visual representation that is meaningful to providers. Some examples are the FACES Pain Scale-Revised and the Wong-Baker Scale. These scales were created for children ages 3 to 8 years; however, the reliability of these scales has been shown to increase with age and the child’s cognitive ability.24 For older children, visual analog scales are replaced by horizontal numeric scales that use a linear gradient to qualify pain on a scale from 0 to 10. These scales are reserved for children 8 to 11 years of age. Adolescents are able to rate their pain using a numeric scale without the need for visual cues and also can be prompted with questions to identify different characteristics of their pain (i.e., location, duration, frequency, and worsening/alleviating factors).1
Providers should not rely solely on pain scales to measure discomfort. Families of patients may be able to give clues as to how the patient appears when they are in pain. This is especially useful for nonverbal children with cognitive impairment. The most effective pain assessment is done in conjunction with the patient, the patient’s caregivers, and the healthcare providers.
Non-pharmacologic Strategies: Non-pharmacologic strategies refer to interventions that do not use medication or pharmacologic agents to reduce pain. The benefits of using non-pharmacologic methods include decreased pain, distress, and anxiety reported by the parent, child, and/or observer.11 These methods have proven to be highly effective in EDs and can be used alone or in combination with pharmacologic strategies when possible.
Non-pharmacologic strategies can be divided into physical approaches and cognitive-behavioral strategies. Common physical strategies can include warm and cold compresses, pressure, vibration, massage, and immobilization.11,13 These procedures require minimal resources and prove highly effective in a busy ED setting.
Cognitive-behavioral strategies are largely dependent on the patient’s age and development. For example, common non-pharmacologic strategies for infants in pain include pacifiers/non-nutritive sucking, swaddling, rocking, singing/music, and sucrose administration.11 For young children, distraction techniques with toys and books commonly are used, while video games or computers are often used with adolescents.11
Pharmacologic Strategies: Once a child’s level of pain has been quantified using an age-appropriate pain scale and non-pharmacologic methods have been applied, it can be triaged appropriately. (See Figure 1.) In general, pain that is ranked on the lower end of most scales can be treated with first-line analgesics, such as acetaminophen and ibuprofen, while severe pain that is ranked on the higher end is usually treated with opioids. For the purposes of this article, a suggested pain management protocol will be reviewed, followed by a discussion of targeted pain management for common minor procedures (i.e., venipuncture, sutures, lumbar puncture, urethral catheterization, etc.).
Acute Pain Management
Most pediatric EDs have evidence-based protocols for management of acute pain. Non-pharmacologic strategies should be used in combination with pharmacologic agents when possible. For example, a young child who requires sutures would benefit from the application of a topical anesthetic in addition to an explanation of the procedure by a child life specialist and age-appropriate distraction techniques.
How To Better Incorporate Pain Management in the ED
Pediatric ED providers must be able to treat acute pain in a timely manner, via an appropriate route with an appropriate agent. Pain also must be monitored periodically post-intervention to evaluate whether there has been an adequate response to treatment.15 Pain management for general acute pain can be organized by the framework provided by the ED patient flow as seen in Figure 1.
Figure 1. Analgesic Algorithm for Use in the Emergency Department |
 |
|
Adapted from: Bailey B, Trottier ED. Managing pediatric pain in the emergency department. Paediatr Drugs 2016;18:1179-2019. |
Nonsteroidal anti-inflammatory drugs (NSAIDs) are an excellent choice for mild to moderate pain in the ED setting. (See Table 2.) There are many different types of NSAIDs, including ibuprofen, naproxen, and ketorolac; however, when NSAIDs are given in equipotent doses, there is little if any difference in analgesic efficacy, including the intravenous (IV) vs. oral routes of administration.30 Ibuprofen is the most commonly used NSAID and is available via IV and enteral routes for patients who are 6 months of age and older. Limited data are available for infants younger than 6 months of age. NSAIDs are contraindicated for active gastrointestinal bleeding, bleeding disorders, and previous hypersensitivity reactions. They also are contraindicated in patients with renal failure because they increase the risk of acute kidney injury. In addition, some providers have supported the relative contraindication for the use of NSAIDs in patients with acute fractures, as a few studies have suggested that the use of NSAIDs in these patients can cause poor bone healing.30 Although the role of NSAIDs in fracture healing has been supported in animal models, there is no robust evidence to suggest significant harm resulting in short-term use of NSAIDs following a fracture in adult populations.31 Few comprehensive studies investigating NSAID use and bone healing have been conducted in pediatric populations.
Table 2. Pain Medications for Acute Mild to Moderate Pain in a Patient Without IV Access |
||
|
Route |
Dose |
Special Considerations |
|
Oral ibuprofen |
10 mg/kg/dose every 6-8 hrs Providers should not exceed |
Limited data are available for infants younger than 6 months of age. Contraindicated for gastrointestinal bleeding, bleeding disorders, previous hypersensitivity reactions, and chronic kidney disease. |
|
Oral acetaminophen |
10-15 mg/kg every 6 hrs OR 10 mg/kg every 4 hrs Providers should not exceed |
Special care should also be taken to avoid other medications containing acetaminophen. Due to risk of liver toxicity, should not be used in patients with hepatic failure. |
|
Rectal acetaminophen |
10 mg/kg/dose every 4 hours OR 15 mg/kg/dose every 6 hours Do not exceed 60 mg/kg/day or |
See oral acetaminophen. Inaccurate dosing may occur with rectal administration because of unequal distribution of acetaminophen in the suppositories. Rectal administration should be avoided in patients suspected of being neutropenic. Although the use of high-dose rectal acetaminophen (i.e., 25-45 mg/kg/dose) has been investigated in several studies, its routine use remains controversial. |
Acetaminophen is another effective first-line pharmacologic agent for mild to moderate pain because of its timely onset of action and relatively low side effect profile. Acetaminophen is available via enteral, rectal, and IV routes. Enteral and rectal acetaminophen are used most commonly in the ED, given their ease of use and the fact that there is no need for special access. Rectal administration can aid in pain management in a patient without access who is unable to tolerate oral medications; however, rectal administration produces delayed and variable uptake. Studies have shown a single dose of 35-45 mg/kg per rectum generally produces therapeutic plasma concentrations in pediatric populations and a single dose of 20 mg/kg can produce safe plasma concentrations in preterm neonates.32 This dosing results in prolonged clearance and thus a longer duration. When using this technique, subsequent rectal doses should be smaller (i.e., 20 mg/kg/dose) and the doses should be spaced at least 6-8 hours.33
If a patient presents with moderate to severe pain, it is also reasonable to consider opioid medications. The administration of opioids long has been a controversial topic in emergency medicine. Many working ED physicians have significant “opiophobia,” the fear of prescribing opioids, stemming from the lack of proper knowledge about opioid analgesics, fear of masking an acute illness, or concerns about addiction or dependence.9 Additional barriers include the general fear of prescribing potent opioids to children and a limited confidence in the assessment of pediatric acute abdominal conditions by referring physicians.9,34
The choice of opioid therapy depends on many factors, including provider preference and comfort. Children with acute moderate pain typically are treated with a low dose of a strong opioid such as morphine, oxycodone, hydromorphone, or fentanyl.1 Combination products of acetaminophen with opioids also have gained popularity, although they should be used with caution because of the increased risk of acetaminophen overdose. In 2011, the FDA issued a request that providers stop prescribing combination drug products that contain more than 325 mg of acetaminophen per tablet, capsule, or other dosage unit to prevent the risk of severe liver injury from inadvertent acetaminophen overdose.35 Combined opioid/acetaminophen medications with smaller amounts of acetaminophen, such as hydrocodone/acetaminophen, since have come into favor among ED providers. (See Table 3.)
Table 3. Common Opioid Analgesics for Use in the Emergency Department |
||||
|
Drug |
Dose |
Onset |
Duration |
Special Considerations |
|
Fentanyl (IN) |
1.5-2.0 mcg/kg Use 100 mcg/2 mL concentration Titration is possible every 15 min Do not exceed 1 mL per nostril. |
5-10 min |
1 hr |
Best for treatment of acute, severe pain in patients without IV access Deliver half of the medication dose up each nostril to double available mucosal surface area and increase the rate of absorption |
|
Fentanyl (IV) |
1-2 mcg/kg/dose every 1 hour as needed |
3-5 min |
30-60 min |
Short-acting. Consider longer acting opioids when prolonged pain in expected. |
|
Hydrocodone/ Acetaminophen |
Hydrocodone dose: - If < 50 kg: 0.2 mg/kg/dose of hydrocodone every 4-6 hrs - If > 50 kg: 2.5-10 mg hydrocodone every Max acetaminophen dose: If < 40 kg: 15 mg/kg/dose (max 1000 mg/dose); if > 40 kg, max 1000 mg/dose and 4000 mg/day |
10-20 min |
4 hrs |
Safety not established in children < 2 years old Available Dosage Forms: Tablet: 2.5 mg/325 mg; 5 mg/300 mg; 5 mg/325 mg; 7.5 mg/ Oral solution/elixir: (7.5 mg/325 mg)/15 mL; (7.5 mg/500 mg)/15 mL (10 mg/300 mg)/15 mL; (10 mg/325 mg)/15 mL |
|
Hydromorphone (Dilaudid®) (PO) |
0.03-0.08 mg/kg/dose every 3-4 hrs (Initial max dose: 0.5-2 mg) If > 50 kg: 1-2 mg/dose every |
10-15 min |
2-3 hrs |
Limited data are available for use in infants and children younger than 2 years of age Feasible alternative for the management of acute pain in the ED when a patient requires a large bolus of opioid analgesics |
|
Hydromorphone (Dilaudid®) (IV) |
0.015 mg/kg/dose every 4 hrs as needed
|
30 min |
4 hrs |
PO to IV conversion for hydromorphone is |
|
Morphine (IV, IM, SC, PO) |
IV or IM: 0.05-0.2 mg/kg/dose every 2-4 hrs as needed (Initial max dose: 4 mg/dose) PO: 0.1-0.5 mg/kg/dose every 4-6 hrs as needed (Initial max dose: 15-20 mg) |
2-3 min (IV) 10-30 min (IM) ~20 min (SC) ~30 min (PO) |
3-5 hrs |
Intramuscular and subcutaneous routes should be considered as a last resort in patients for whom providers are unable to obtain IV access |
|
Oxycodone, immediate release (PO) |
0.05-0.15 mg/kg/dose every 4-6 hours as needed (Initial max dose: 20 mg) |
10-30 min |
3-6 hrs |
May prescribe small amounts for breakthrough pain at discharge for patients expected to have intermittent severe pain |
|
Sufentanil (IN) |
0.5-0.7 mcg/kg Use 50 mcg/mL concentration |
5-10 min |
1-2 hrs |
Consider when large volumes of IN fentanyl are required Consider administering with an antiemetic, as a common side effect is vomiting |
|
Abbreviations: intravenous (IV), intramuscular (IM), subcutaneous (SC), oral (PO), intranasal (IN) * Opioids may cause respiratory depression. Always have the patient on oxygen monitors and have naloxone available. Caution should be taken when using acetaminophen and opioid combinations in children to avoid potential acetaminophen overdose with titration. |
||||
Common side effects of opioids include nausea and emesis. Several studies have demonstrated that the routine use of antiemetics is not necessary in adult ED patients, as the incidence of nausea and vomiting is relatively low; however, there are no major studies that have been conducted in pediatric patients to support or refute the benefit of routine use of antiemetics with opioids.36,37,38
Opioids generally are administered orally or intravenously in the ED. In emergency situations involving patients with difficult access, providers may attempt intraosseous, intranasal, intramuscular, and subcutaneous routes. Because opioids are most commonly delivered intravenously, providers should consider topical anesthetics during triage for patients who likely will require IV medications, as IV placement is often a painful procedure for most pediatric patients (see targeted pain section below). When administering opioids, it is important that the patient is placed on continuous oximetry because of the risk of respiratory depression.
Codeine (3-methylmorphine) is a naturally occurring methylated morphine that has been used for decades for its analgesic and antitussive properties; however, it has become widely unpopular because of its unpredictable effect and risk of respiratory depression and even death due to interpatient variation of its metabolism to morphine by the cytochrome P450 2D6 (CYP2D6) enzyme system. Pain medications containing codeine (i.e., Tylenol no. 3) were removed from the World Health Organization list of essential medications in March 2011 because the “efficacy and safety were questionable in an unpredictable portion of the pediatric population.” It also received a “black box warning” by the FDA in February 2013 for its risk of respiratory depression when used in postoperative tonsillectomy and adenoidectomy patients.39 Codeine still may be used in older pediatric patients without respiratory issues in the ED; however, extreme caution should be used when prescribing this drug.
Common opioids include morphine, hydromorphone, and fentanyl. (See Table 3.) Morphine is the recommended first-line treatment for moderate to severe pain because of its effectiveness and short half-life. Morphine commonly is given intravenously, but it also can be given intramuscularly or subcutaneously in patients without IV access. Hydromorphone is considered a more potent opioid than morphine because of its higher lipid solubility; and IV fentanyl offers the advantage of a shorter onset and duration of action than morphine. Hydromorphone is a feasible alternative for the management of acute pain in the ED when a patient requires a large bolus of opioid analgesics.40
Intranasal fentanyl has gained popularity when compared to IV opioids for treatment of moderate to severe pain for pediatric patients in the ED because of its fast onset and ease of administration.41 Protocols can be established for its use, indicating appropriate dosing by weight and appropriate administration with an atomizer. In general, administration is painless and minimally distressing for children.41 Studies also have shown that pain control with intranasal fentanyl is equivalent to that of IV morphine.32,41
Providers should be aware of the volume dispensed with intranasal medications. Small volumes of 0.2-0.3 mL per nostril are ideal, whereas volumes that exceed 1 mL per nostril are not absorbed reliably because of mucosal saturation and runoff from the nasal cavity.42 For older children, intranasal sufentanil may be a beneficial alternative, as it results in less volume of administration because it is 10 times more potent than fentanyl. Special care should be taken when administering sufentanil, as a common side effect is vomiting. Providers should consider administration with an antiemetic, although there is no evidence supporting prophylactic antiemetics with these medications. Both intranasal fentanyl and intranasal sufentanil have rapid onset and a short duration. Therefore, providers should coadminister an oral analgesic or obtain immediate IV access for administration of additional longer acting analgesics shortly after the administration of intranasal fentanyl or sufentanil.
Special care should be taken when combining opioids with benzodiazepines because of their sedative effect. Patients always must be placed on monitors during concomitant use of these medications because of the risk of central nervous system depression, leading to decreased respiratory status and death. Often, combinations of these medications are used intentionally together in the ED setting for procedural sedation; however, that is beyond the scope of this article.43
Targeted Pain Control for Minor Procedures
Pediatric patients are exposed to a variety of procedures in the ED, including venipunctures/IV insertion, intramuscular injections, lumbar punctures, sutures, and urine catheterizations. In these situations, special pain management techniques can be applied to the non-sedated pediatric patient. Pediatric EDs should establish protocols for routine use of these adjuncts by the staff who perform these minor procedures.
Topical Anesthetics Available for Procedures Involving Needles
Fast-acting topical numbing sprays and solutions can offer quick and effective pain control for procedures involving needles. These formulations also are available in patch forms to facilitate use. Vapocoolant sprays cool the skin surface immediately prior to venipuncture, IV placement, or intramuscular injections; desensitize skin pain receptors; and/or inhibit spinal cord pain signals by a specific cold temperature nerve impulse.44 Examples of these sprays include Fluo-Ethyl, Pain Ease, and Instant Ice. Fluo-Ethyl combines ethyl chloride with dichlorotetrafluoroethane, while Pain Ease and Instant Ice contain 1,1,1,3,3,-pentafluoropropane and 1,1,1,2,-tetrafluoroethane in spray form, which is not flammable or ozone depleting. These solutions should be used on intact skin only and should not be used around the eyes or in patients with poor circulation or sensitive skin. Other options for pain management during needle procedures include the application of topical analgesics such as LMX-4 (lidocaine 4%) and EMLA. (See Table 4.) However, because of their longer duration of onset, they require early application in triage.
Table 4. Topical Anesthetics for Use in the Emergency Department |
|||
|
LET (4% lidocaine, 1:2000 |
EMLA (eutectic mixture of local anesthetics) (2.5% lidocaine and 2.5% prilocaine) |
LMX-4 (Lidocaine 4%) |
|
|
Application |
Apply 1-3 mL directly to wound for 15-30 min prior to procedure (max dose 4 mg/kg of lidocaine or 280 mg) Available as a topical cream or patch Should not be applied to mucous membranes or areas that are supplied by terminal arteries (i.e., fingers, nose, penis, toes) |
Apply a thick layer of 1-2 g per 10 cm2 to intact skin and cover with an occlusive dressing for 1 hr. Efficacy is variable depending on duration of application. |
Apply a thick layer of 1-2 g per 10 cm2 to intact skin. Max doses: 1 g if < 5 kg, 2 g if body weight 5-10 kg, 10 g if body weight 10-20 kg, 20 g if body weight >20 kg. Do not apply to an area greater than 100 cm2 in children < 10 kg. Do not apply greater than 200 cm2 in children between 10-20 kg Should not be applied to mucous membranes or areas that are supplied by terminal arteries (i.e., fingers, nose, penis, toes) |
|
Onset of Action |
20-30 min |
1 hr |
20-30 min |
|
Duration of Action |
1-2 hrs after occlusive dressing removal |
30 min to 2 hrs after occlusive dressing is removed |
1 hr |
|
Adverse Events |
May cause contact dermatitis or methemoglobinemia (rare) |
May cause contact dermatitis or methemoglobinemia (rare) Has been used for anesthesia in laceration repair although not FDA-approved for this purpose |
Some reports of local reactions (redness, irritation, itching, rash) when applied to intact skin |
Additional Tools Available for Laceration Repair
Topical Analgesics: Topical analgesics are used widely in pediatric populations. They are useful for procedures involving needles and in preparation for laceration repair. The earliest creams contained combinations of 11.8% cocaine, 0.5% tetracaine, and 1:2000 epinephrine known as TAC; however, cocaine-free preparations have proven to be equally effective with fewer documented side effects. TAC is no longer available in the United States. Common topical analgesics that can be used in wound repair include LET (4% lidocaine, 1:2000 epinephrine, 0.5% tetracaine) and EMLA (eutectic mixture of local anesthetics; 2.5% lidocaine and 2.5% prilocaine). (See Table 4.) LET and EMLA are considered superior to TAC because of their cost-effectiveness and superior safety record.45 LET is approved for use in non-mucosal open wound repair.45 EMLA cream also can provide anesthesia for laceration repair, although it is not FDA-approved for this purpose.23 However, when it is used for this purpose, gauze is saturated in a solution of EMLA, which is applied directly to the lacerations and covered with an occlusive dressing. EMLA and LET have been approved for use in all populations, including neonates.
Local and Regional Anesthetics: Local and regional anesthetics commonly are used for procedural pain control in pediatric populations. (See Table 5.) Local anesthesia involves the subcutaneous injection of an anesthetic drug into a small area, which causes numbness in a specific area (i.e., a small patch of skin). For regional anesthesia, the anesthetic block is directed at the trunk of a nerve and affects all the branches of the nerve that are derived from that trunk, resulting in a larger area of numbness (i.e., an entire arm or below the waist). The two most common regional and local anesthetics used in the ED are lidocaine and bupivacaine. Lidocaine can be used alone or applied after the application of topical anesthetics. Lidocaine can produce a stinging sensation because of its acidity when applied alone. To minimize the stinging sensation associated with lidocaine administration, it should be injected using the smallest gauge needle possible. The solution also can be warmed or buffered with bicarbonate in a 1:10 solution.23 Bupivacaine also can be used for regional anesthesia. It offers a longer duration of action than lidocaine and, therefore, is ideal for lengthy procedures including spinal blocks and high-quality sensory blocks.
Table 5. Regional Anesthetics for Use in the Emergency Department |
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|
Anesthetic |
Dose |
Onset |
Duration |
Special Considerations |
|
Lidocaine |
Max dose 5 mg/kg |
< 2 min |
1-2 hr |
Can be buffered with bicarbonate in a 1:10 solution or warmed to reduce stinging sensation during injection. Watch for early warning signs of central nervous system toxicity (i.e., restlessness, anxiety, incoherent speech, lightheadedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus, dizziness, blurred vision, tremors, depression, or drowsiness). More likely if injected intravenously. |
|
Lidocaine with epinephrine |
Max dose 5 mg/kg |
< 2 min |
2-6 hrs |
Epinephrine is added to lidocaine to reduce lidocaine toxicity, prolong duration of anesthesia, and to control bleeding. |
|
Bupivacaine 0.25% |
Max dose 1 mg/kg |
5 min |
2-4 hrs |
Patient should be on monitors during anesthetic injection. Watch for early warning signs of central nervous system toxicity (i.e., restlessness, anxiety, incoherent speech, lightheadedness, numbness and tingling of the mouth and lips, metallic taste, tinnitus, dizziness, blurred vision, tremors, depression, or drowsiness). More likely if injected intravenously. |
|
Bupivacaine 0.25% with epinephrine |
Max dose 1 mg/kg |
5 min |
3-7 hrs |
Patient should be on monitors during anesthetic injection. The addition of epinephrine causes a longer duration of action. |
Non-Pharmacologic Techniques: In some cases, non-pharmacologic techniques can replace traditional methods for decreasing pain during laceration repair. For example, topical tissue adhesives have become increasingly popular in the ED. Tissue adhesives such as Dermabond®, Indermil®, and Histoacryl® can be used as alternatives to sutures for superficial tissue approximation in lacerations, such as facial lacerations and selected extremity and torso lacerations under minimal tension.47 When used in areas with dense hair, such as the scalp, caution should be taken to make sure hair does not get into the wound. It is important to note that while tissue adhesives do not cause pain, they can produce a warm sensation temporarily when applied to the skin because they polymerize through an exothermic reaction. Tissue adhesives never should be applied directly into a wound or used on mucosal surfaces or mucocutaneous junctions. They also should be avoided in infections, gangrene or ulcerations, animal bites, areas of high moisture, partial thickness skin loss, or moderate to high tension areas such as over joints.48
Wound closure tapes are another alternative for laceration repair. Wound closure tapes, such as Steri-Strips with or without benzoin, are easy to apply and pain-free, which offers a major advantage for pain control for minor, low-tension wounds.47 Wound closure tapes are indicated for very small wounds (< 1-2 cm) with very little tension, such as the face and tips of the fingers that are already homeostatic.49
Small lacerations of the scalp can be approximated using a hair apposition technique initially described in 2002 in which manual twisting and gluing of the scalp hair bundles to close wounds in place of sutures or staples.50 Follow-up studies have shown that the hair apposition technique can be used safely in the repair of linear scalp lacerations; this method has the advantage of being more satisfying, with lower rates of cosmetic problems and complications in comparison to suturing and stapling techniques.51
Tools Available for Urine Catheterization
Bladder catheterization is a commonly performed painful procedure in the pediatric population in the ED. Viscous lidocaine (“lidocaine jelly”) has been used by providers to minimize pain associated with this procedure. This has been well supported in the literature for the adult population, although there is a paucity of data in the pediatric population.52,53,54 In the few studies that exist for the pediatric population, the findings have shown mixed results. A 2009 randomized, double-blind study evaluated whether the use of topical and intraurethral lidocaine would decrease distress in infants ages 2 to 24 months receiving urethral catheterization; the authors found that its use resulted in lower distress than the topical lubricant with standard catheterization, although it did not completely eliminate pain.55 A more recent 2015 randomized, blinded, placebo-controlled trial showed that in 133 infants, ages 0 to 24 months, a topical and intraurethral lidocaine was not associated with significant pain reduction during urethral catheterization, but significantly greater pain during instillation.56 Despite the evidence to the contrary, many clinicians continue to use lidocaine to alleviate pain associated with urethral catheterization. Since the evidence is not strong enough to support such a practice, pain relief during these procedures should be focused on noninvasive methods and joint decision-making with parents.
Discharge Medications
Pain medication should be provided upon discharge for patients expected to continue to experience some level of pain after their visit. The physician should pay attention carefully to dosing and length of therapy when prescribing analgesics, especially with opioids. All patients should receive clear, written instructions that include information about expectation of pain duration, as well as medication dosing, duration, and adverse effects. Instructions for non-pharmacologic therapies (i.e., warm and cold compresses) also should be given routinely.
Outpatient Opioid Use in the Pediatric Population
The administration of opioids should not be delayed for severe pain; however, providers should be aware of increasing trends in opioid abuse over the past decade, especially among adolescents, and be able to mitigate those risks. Data from the National Survey on Drug Use and Health found that in 2014, more than 460,000 adolescents were current non-medical users of pain relievers and 168,000 adolescents had an addiction to prescription pain relievers. Data from the 2001-2010 National Hospital Ambulatory Medical Care Survey showed that the overall use of opioid analgesics in pain-related pediatric ED visits increased from 11.2% to 14.5% between 2001 and 2010, and the use of Drug Enforcement Agency schedule II agents doubled from 3.6% in 2001 to 7.0% in 2010.57 Nearly 13% of high school seniors report nonmedical use of a prescription opioid, and the most common method of obtaining opioids was from a prior medical prescription.58 These findings have medical implications, including an increase in accidental opioid-associated overdose and opioid-related deaths in this population.57
Inappropriate use of opioids can be combated by ED providers by educating patients and families on addiction and misuse, adhering to practices that limit the over-prescription of opioids, using prescription drug monitoring programs, and using adjunctive, non-opioid and non-pharmacologic treatments during and after the visit. Although screening for individuals at risk for opioid misuse would help prescribers cut down on opioid misuse, no validated screening measures have been created specifically for this purpose. Providers should pay attention to the indications for opioid prescribing, indications for short- vs. long-acting opioids, and appropriate duration for discharge prescribing. For example, providers should prescribe a short course (up to 3 days) of opioid or combination opioid/acetaminophen medication for acute pain conditions that require opioids.59 Long-acting or controlled-release opioids, such as OxyContin, fentanyl patches, and methadone, should not be prescribed in the ED for acute pain, as these require long-term monitoring for pain relief and signs of dependence and addiction, which realistically cannot be provided by ED physicians.60,61 Providers also should avoid providing replacement prescriptions for controlled substances that were lost, destroyed, or stolen, and should refer the patient back to the provider responsible for prescribing these long-term medications.59,61
SUMMARY
Although major advancements have been made toward closing the gap of oligoanalgesia in pediatric patients in the ED, there remains room for improvement. These recommendations provide suggestions for improvement in today’s setting, but newer techniques are developing, which challenge providers to continue to learn and adapt to the ever-changing ED environment.
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Pain management in the pediatric population has long been a focus of healthcare providers; nevertheless, gaps in providing adequate and timely pain management remain an area of concern in EDs. This article will provide guidance for the recognition and successful management of pediatric pain in the ED setting. The authors first present definitions of pain and discuss the assessment of pain in a child, as well as common barriers to appropriate pediatric pain management in the ED. Then, the article will focus on the different aspects of pain and techniques of managing discomfort, including: anxiolysis, non-pharmacological strategies, topical medications, oral analgesics, parenteral medications, discharge medications, and misconceptions and facts about opioid analgesics. Pain control in conjunction with procedural sedation is beyond the scope of this article.
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