Pediatric Pain Control
August 1, 1999
Pediatric Pain Control
Author: Marc S. Lampell, MD, FACEP, Director, Pediatric Emergency Department, Rochester General Hospital, Assistant Clinical Professor Pediatrics and Emergency Medicine, University of Rochester School of Medicine
Peer Reviewer: Marc S. Leder, MD, Assistant Professor of Clinical Pediatrics, Attending Physician, Pediatric Emergency Medicine, Children’s Hospital, Ohio State University, Columbus, OH.
Of all the symptoms that prompt patients to seek medical attention, none is so prevalent as pain. Pain is an unpleasant sensory and emotional experience usually defined in terms of tissue damage. Pain is a nonspecific localized sensation of discomfort, distress, or agony resulting from the stimulation of specialized nerve endings that serve as a powerful stimulus and also teach young children to avoid danger. The perception and response to pain is subjective and may be modified by social, cultural, and psychological factors. (See Table 1.)
Painful procedures are a major source of distress in children. The number of "sticks" that are necessary for the diagnosis and treatment are often worse than the disease itself.
The relief of pain and suffering has been considered one of the most laudable of physicians’ goals. Until recently, the prevailing dogma was that children did not perceive pain or remember pain occurrences as intensely or as unpleasantly as did adults, even though nociceptive neural pathways are in place by 24 weeks gestation. Some physicians fear that administering opioids will mask the symptoms of an injury. Studies in adults have shown an equal, if not improved, ability to diagnose intra-abdominal pathology after narcotics administration.14 Many practitioners withhold opioids or administer inadequate doses because of fear of serious side effects such as respiratory depression or hypotension. The potential for these adverse effects is real, but knowledge of the pharmacokinetics of any drug and utilization greatly reduces the risk. Another erroneous belief is that children are at increased risk for narcotic addiction. In reality, the risk of addiction from short-term use of opioids is extremely low. Such assumptions are false, and it is no longer appropriate simply to restrain children or to withhold analgesia.
Although pain is a common reason to seek emergency care, adequate pain management of the child in the emergency department (ED) has only begun to be addressed recently. Contributing factors such as fear of complications, obscuring diagnoses, failure to appreciate the severity of the pain, preoccupation with treating the underlying emergency problem, and lack of training are reasons for this delay in recognizing and treating pediatric pain. Children are less likely than adult patients to receive an analgesic for the same condition.15-20 Providing effective analgesia for children is a necessary skill in emergency medicine that is now being emphasized in emergency medicine training programs. Newer, more reliable, ultra-short acting agents require the clinician to develop new skills, monitoring techniques, and knowledge of drugs and doses.
The goal in the ED is to enhance patient cooperation and compliance by relieving anxiety and controlling pain while maintaining patient safety and health. When formulating a management plan, practitioners should consider not only the requirement for efficient performance of the procedure but also individual factors, such as developmental level, physical condition, and prior health care experiences. Appropriate interventions may include both non-pharmacologic techniques and pharmacologic agents. By providing sedation, analgesia, and anxiolysis, children can undergo procedures with minimal physiologic or emotional distress. This article reviews recommended guidelines for administration, monitoring, and management of patients undergoing sedation for diagnostic and therapeutic procedures and discusses various sedative, analgesic, and anesthetic alternatives available to clinicians.
—The Editor
Introduction
Pain relief in children is a topic that historically has received little attention. Most standard pediatric textbooks devote little if any space to a discussion of the causes and treatment of pediatric pain.15-20 The American College of Surgeons states in the chapter on "Extremity Trauma" in the 1989 edition of the ATLS text that "analgesics should be used sparingly, if at all." A worldwide literature search in the 1970s for English written articles on pain revealed only 33 of 1380 (2.5%) articles dealt with pain in children.15-20 A study of postoperative pain in the early 1980s showed that although 40% of children suffered moderate to severe pain, more than half the patients received no pain medications. After cardiac surgery, children have been shown to receive significantly less pain medication than adults. Even when analgesia is ordered, less potent medications are often prescribed, smaller doses (adjusting for body weight) are given, fewer overall doses are administered, and discontinuation or conversion to less potent analgesics is done sooner than in adult counterparts.
As recently as 1990, Selbst and Clark reported in a retrospective study that 60% of adults, but only 28% of children, presenting to an ED received adequate analgesia.17 Only 37% of pediatric patients with lower extremity fractures received any analgesics, and only 24% of those with second- or third-degree burns received analgesics in the ED. In 1997, Petrack, Christopher, and Kriwinsky documented a rate of analgesic use for long bone fractures of 53% in children and 73% in adults.7 This represents a significant improvement, but remains inadequate. In 1993, Todd et al reported that in Los Angeles, Hispanics were less likely than Caucasians to receive analgesics for an isolated long bone fracture. Surprisingly, pediatricians gave less pain medication than emergency physicians, although this was not statistically significant. Altogether, these reports continue to demonstrate what Wilson and Pendleton have justly termed "oligoanalgesia."16 Fortunately, over the last 15 years there has been a dramatic increase in the focus on pain relief, as evidenced by the immense number of articles on pain in the more recent medical literature. Although most studies were done initially on adults, there is now a large body of experience and knowledge in treating acute pain in children.
Undertreatment of pain in infants and children undergoing painful procedures is no longer considered a tolerable practice. Uncontrolled pain and anxiety produce frightened and uncooperative patients, who may also experience significant physiologic and psychologic consequences. Thus, effective management of procedure-related anxiety and pain yields immediate and long-term benefits to the patient and parents, as well as health care providers.
Historical Misperception
Misperception 1: Infants do not feel pain. It was widely believed in the medical community for years that newborns and older infants did not feel pain. One reason often given was that an immature or incompletely myelinated central nervous system (CNS) in infants didn’t allow transmission of a painful stimulus. Another rationale was that infants possessed a high pain threshold as an adaptive mechanism for pain during birth. A corollary to this belief was that even if infants felt pain, they didn’t suffer because of cognitive immaturity and, therefore, an inability to remember the painful experience.
Ample scientific evidence now exists to refute this misperception. Anand and Hickey note that the neurotransmitters and peripheral and central neural pathways necessary for pain transmission are intact and functional by 29 weeks gestation. At birth, pain inhibitory systems are not fully developed, and there is a potential for young infants to have a magnified stress response when exposed to pain. Cardiorespiratory, hormonal, and metabolic responses to pain common in adults have also been documented to occur in neonates. Although simple behavioral changes associated with pain are present, such as crying, facial expressions, and purposeful withdrawal of a limb, there is also evidence that the capacity for memory at this age is much greater than previously suspected. In one study of pain responses to immunizations, circumcised boys had greater stress responses than non-circumcised boys, and boys who had received Eutectic Mixture of Local Anesthetics (EMLA) for circumcision had a lower stress response than boys who had not received EMLA.18,21,22
Misperception 2: It is not possible to quantify pain in infants and children. Depending on developmental age, the pediatric patient may be unable or unwilling to verbalize or quantify pain. Nonetheless, a number of pain assessment scales have been developed and have been shown to be reliable in both infants and children. Specialized, developmentally appropriate self-reporting scales can be used in patients as young as 3 years of age. In addition, facial expression pain scales may be used in younger children.
Misperception 3: Infants and children are more sensitive to the respiratory depressant effects of narcotics. This has led to pervasive recommendations that opioids should be withheld or given in smaller doses to the pediatric patient. More recent pharmacokinetic studies of fentanyl in children have shown that plasma concentrations of fentanyl decrease more rapidly in infants than adults, and that infants older than 3 months of age are not more prone to fentanyl induced respiratory depression.37,38
Misperception 4: Pain may be a necessary part of life and possibly therapeutic. This myth descended from the Puritans, who believed that suffering made a person strong. This belief is refuted by multiple studies showing an increased incidence of complications from stress in both adults and neonates.18
Misperception 5: Adolescents are at high risk for narcotic addiction. This is a rare problem and typically occurs in the occasional adolescent who is already addicted to street drugs and is not using drugs to combat pain.
Pain Perception
Children’s perceptions of pain are influenced by many factors, including expectations, parental response, context, and cognitive level. (See Table 1.) Children’s expectations of pain come very early from their own memory of previous painful experiences and those learned from family or culture. For example, a 6-month-old will withdraw when a needle is brought into his field of vision. Often, expectation and waiting are the worst part of a painful experience. Children are very perceptive of their parents’ emotional responses, and the perception of parental anxiety can increase a child’s pain; a calm parent can be a strong analgesic. The perceived cause and expected duration of the pain can modulate pain perception profoundly.
As children develop, their ability to understand, cope with, and describe pain changes dramatically. The preverbal infant can communicate pain only through behavior and physiologic changes. Pain behavior is characterized by the thrashing of extremities; attempts to touch the affected area; facial grimacing; a tense, cupped tongue; and a high pitched, harsh, irregular cry. These behaviors are very consistent across genders and cultures. Infants also rely heavily on external cues for coping. Soothing practices, such as swaddling, sucking, and stroking, have been shown to reduce an infant’s physiologic and behavioral responses to pain.
Words for pain such as "owie" and "booboo" are some of the first words a preschool age child learns. By 3 years of age, children can begin to assess pain intensity reliably by using a self-reporting scale such as the faces scale. Even though the preschool age child has developed language to communicate pain, his lack of understanding and inability to localize the pain often create confusion for caretakers. Preschool children have very little concept of what is inside their bodies. Any pain that is not on the surface or hasn’t caused a visible injury may be poorly localized (e.g., the vague complaint of a "tummy ache").
School age children have a much broader understanding of pain. Children at this age begin to use psychologic coping mechanisms such as distraction. They have developed a greater understanding of their bodies. This enables them to locate internal pain better. Along with this increased awareness comes the awareness of mortality, which can exacerbate fear and pain perception greatly.
For the adolescent, the psychological effects of pain and injury are paramount. The primary focus for this group includes concern over alteration of body image, loss of relationships with peers, and maintenance of personal control. These issues may cause anxiety and may heighten pain perception. Along with the greater understanding of the psychological aspects of pain comes the ability to describe pain more precisely in terms of quality and timing. Adolescents are better able to use cognitive coping strategies to diminish the perception of physical pain.
Pain Physiology
Pain receptors, or nociceptors, are present to a varying extent in all tissues. Some, such as the brain, have few while others, such as the fingers, have countless pain receptors. Noxious stimuli are transmitted to the spinal cord by A-delta and C peripheral nerve fibers. After entering the CNS, the signal is passed up ascending tracts in the spinal cord to synapse in specific areas of the midbrain, pons, and diencephalon. At any point along the path, reflex arcs may be stimulated to initiate aversion responses to the noxious event. From these lower brain centers, the nociceptive information may be forwarded to the limbic areas of the telencephalon, where the subjective, conscious experience of pain originates. A-delta (myelinated and fast conducting) fibers transmit sharp, well localized, "somatic" pain that originates from the skin, periosteum, pleura, and peritoneum. C fibers (unmyelinated) originate from skin as well, but are primary pain afferents from joints, muscles, and viscera such as the lung, heart, bowel, and kidney. This "visceral" pain tends to be dull, agonizing, burning, and poorly localized.
Once stimulated, afferent pain fibers (A-delta and C) promote the release of a mediator known as substance P both at the site of the injury and in the dorsal horn of the spinal cord. At the site of injury, substance P leads to vasodilatation and increased vascular permeability. Local edema and the release of inflammatory mediators (prostaglandins, leukotrienes, bradykinin, serotonin, and histamine) leads to sensitization of nociceptors. At the level of the dorsal horn, substance P acts as an excitatory neurotransmitter. Endogenous enkephalins and endorphins, and exogenous opioids antagonize substance P and its effects.
Pain Assessment
The clinician has many tools for assessing a child’s pain. Often the most reliable is the child’s self-report during questioning, but the child’s cognitive level may affect this reporting. Pain rating scales, evaluation of behavior, physiologic parameters, parental observations, and knowledge of the cause of the pain can all yield important information.
While questioning a child, it is important to use words that he understands such as "booboo" and "owie." Because even some preschoolers can localize pain, all children should be asked to point, with one finger, to the painful spot. Older children can provide detailed information regarding pain intensity, quality (throbbing, stabbing, etc.), duration (constant vs. intermittent), and the factors that affect the intensity of the pain.
Pain rating scales provide a subjective and qualitative measure of pain intensity. Children as young as 3 years of age can use a cartoon facial expression scale. The faces range from happy, which represents no pain, to tearful, which represents the most severe pain a child could imagine. (See Figure 1.) Once children gain a concept of numbers (~ 5 years of age), they are able to self-report with the use of a variety of more abstract scales, including the OUCHER scale. (See Figure 2.) The Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) has been shown to be reliable in children older than 5 years of age. (See Table 2.)
| Table 2. CHEOPS Scale | ||
| Item | Behavior | Score |
| Cry | ||
| No cry | 1 | |
| Moaning | 2 | |
| Crying | 2 | |
| Scream | 3 | |
| Facial | ||
| Composed | 1 | |
| Grimace | 2 | |
| Smiling | 0 | |
| Child Verbal | ||
| Non verbal | 1 | |
| Non pain-related complaints | 1 | |
| Pain-related complaints | 2 | |
| Both complaints | 2 | |
| Makes positive statements | 0 | |
| Torso | ||
| Inactive and Restful | 1 | |
| Shifting torso | 2 | |
| Body arched/rigid | 2 | |
| Body shuddering/shaking involuntarily | 2 | |
| Child upright position | 2 | |
| Body Restrained | 2 | |
| Touch | ||
| Child not touching wound | 1 | |
| Child reaches/doesn't touch wound | 2 | |
| Child gently touches wound | 2 | |
| Child vigorously grabs wound | 2 | |
| Child restrained | 2 | |
| Legs | ||
| Legs relaxed | 1 | |
| Legs restless/squirming | 2 | |
| Legs drawn up/tense | 2 | |
| Standing | 2 | |
| Restrained | 2 | |
In the preverbal child, behavioral and physiologic assessments are necessary to determine pain. The most consistent indicator of pain in infants is the facial grimace. The pain-elicited cry is high-pitched and harsh. In general, the less consolable child is experiencing greater pain. Physiologic signs of pain include increased heart rate, increased blood pressure, and sweating.
No one sign or behavior is an absolute indicator of pain. All pain assessment tools can also be used as measurements of effectiveness of analgesic therapy.
Nonpharmacologic Intervention
Distraction can be a powerful coping strategy during painful procedures. Listening to music through a headset, singing, counting, talking about pets or school, or squeezing the nurse’s or parent’s hand are effective distraction techniques. Since distraction does not directly reduce pain intensity, pain awareness may recur when the child is no longer distracted.
Children capable of abstract thinking may benefit from relaxation and guided imagery. Relaxation techniques, which reduce autonomic activity and, thus, the pain response, include deep breathing, progressive muscular relaxation (systematic tensing and relaxing of muscles), and massage. For younger children, blowing bubbles or a noisemaker can facilitate deep breathing. Even talking to a child in a calm voice encourages relaxation. With guidance, children can use their imaginations to create pleasant images such as floating on a cloud or playing on a beach.
Providing information and choices increase the child’s sense of control. Information should include what is going to happen (e.g., cleaning the wound with "cold" soap, applying anesthetic that may sting or burn, then placing sutures). It is important to be honest when describing anticipated pain. Separation anxiety may be avoided by allowing parents to remain present during the procedure. The presence of a parent usually reduces a child’s distress and helps the child cope with pain. Parents should be instructed about their role and the importance of remaining calm and reassuring during the procedure. Parental presence should be decided on a patient to patient basis.
Papoose boards and other forms of restraint, although debated, are commonly used to immobilize children for short procedures. Such measures are likely to frighten unsedated children and should be explained to the parents beforehand. Nevertheless, restraints at times may be necessary and should be used as an adjunct rather than the primary method of controlling a child’s behavior.
Pharmacologic Approaches
The degree of pain and treatment goals dictate the choice of pharmacologic. The agent(s) selected should provide effective pain relief while having the least interference with other senses. It should have a long effective half-life to minimize daily dosing frequency.
Depending on the degree of pain, the pain medications used for children can be divided into three main categories. Minor pain can be treated with analgesics such as acetaminophen or NSAIDs. Moderate pain is often relieved by addition of an opiate (codeine) to acetaminophen or NSAID. Severe pain frequently requires a potent opioid or the injection of a local anesthetic. (See Table 3.)
| Table 3. Commonly Used Medications | ||||
Indication & Name |
Dose |
Onset |
Peak |
Duration |
| Moderate-Severe Pain | ||||
| Morphine | IV or IM: 0.05 - 0.15 mg/kg q2-4h |
1 min |
5-20 min |
2-4 hrs |
| Hydromorphone | IV: .015 mg/kg q4-6h |
5 min |
30-90 min |
3-5 hrs |
PO: 0.3-0.8 mg/kg q4-6h |
30 min |
|||
| Fentanyl | IV: 1-5 ug/kg/dose |
30 sec |
5-15 min |
30-60 min |
| Transmucosal: 5-15 ug/kg Max 400ug | 5-15 min |
1-2 hrs |
||
| Alfentanyl | IV: 5-20 ug/kg |
30 sec |
20-30 min |
|
| Meperidine | IV or IM: 1-1.5 mg/kg |
10 min |
1-2 hrs |
2-4 hrs |
| Moderate Pain: | ||||
| Butorphanol | IN: one spray (1mg) |
15 min |
30-60 min |
4.5 hrs |
| Nalbuphine | IV: .05 - 0.2 mg/kg q2-4h |
2-3 min |
30 min |
3-6 hrs |
| Oxycodone | PO: 0.1 mg/kg q4-6h |
|||
| Ketorolac | IV: 0.5-1 mg/kg, max 30 mg |
30 min |
1-3 min |
4-6 hrs |
PO: 0.5-1 mg/kg q6-8h |
||||
| Hydrocodone | PO: 0.2 mg/kg tid |
1.3 hrs |
||
| Codeine | PO: 0.5-1 mg/kg q4-6h |
15-30 min |
1-1.5 hrs |
2-4 hrs |
| Mild Pain | ||||
| Ibuprofen | PO: 10 mg/kg q6-8h |
20-60 min |
1-1.5 hrs |
3-6 hrs |
| Acetaminophen | PO: 15 mg/kg q4-6h |
10-60 min |
3-4 hrs |
|
| Aspirin* | PO: 15 mg/kg q4-6h |
15 -20 min |
¾ hrs |
|
| (*not routinely indicated due to risk of Reye's syndrome) | ||||
| Anesthesia | ||||
| Ketamine | IV: 0.5-2 mg/kg |
30 sec |
1 min |
20-30 min |
IM: 2-4 mg/kg |
3-8 min |
15-60 min |
||
PO: 5-10 mg/kg |
10-30 min |
60-180 min |
||
| Propofol | IV: 1-3 mg/kg load |
30 sec |
3-10 min |
|
25-100 ug/kg/min maint |
||||
| Local Anesthetics | ||||
| Lidocaine | 5 mg/kg without epi |
4-10 min |
30-45 min |
90-200 min |
7 mg/kg with epi |
4-10 min |
90-200 min |
||
| Bupivacaine | 1.5 mg/kg without epi |
4-6 hrs |
||
3 mg/kg with epi |
||||
| Mepivacaine | 8 mg/kg without epi |
120-240 min |
||
7 mg/kg with epi |
||||
| Anxiolytics | ||||
| Versed | IV: .05 - .1 mg/kg |
2-3 min |
30-60 min |
|
IM: .05 - .15 mg/kg |
10-20 min |
60-120 min |
||
IN: .2 - .5 mg/kg |
10-15 min |
45-60 min |
||
PR: .25 - .5 mg/kg |
10-30 min |
60-90 min |
||
PO: 0.25 -1.0 mg/kg (max 20 mg) |
10-30 min |
60-90 min |
||
| Antagonists: | ||||
| Naloxone* (Narcan) | IV/ETT/IO 0.1 mg/kg up to 2.0 mg |
|||
in children > 5 yrs |
1-2 min |
30 min |
1.5 hrs |
|
| (*if desired level of consciousness is not achieved, may repeat dose every 60 sec to a maximum of 1 mg) | ||||
| Flumazenil | IV: .01 mg/kg up to 0.2 mg |
1-2 min |
6-10 min |
10-20 min |
Non-narcotic analgesics are the most widely used class of analgesics in the ED. They are useful for treating myriad common pain states including musculoskeletal injuries, headache, dysmenorrhea, etc. The non-narcotic analgesics have gained widespread use because of safety, particularly since these agents are devoid of CNS and respiratory depression and have no abuse potential.
NSAIDs (e.g., Acetylsalicylic acid, Ibuprofen, Naproxen, Ketorolac) are useful in the treatment of mild pain from strains, sprains, non-displaced fractures, first degree burns, and simple dislocation reduction. Acetylsalicylic acid (aspirin), although used very rarely in pediatrics because of its association with Reye’s syndrome, remains the prototype of peripheral analgesics and the standard with which the NSAIDs are compared. NSAIDs block prostaglandin synthesis and the inflammatory response to tissue damage. Orally administered aspirin is rapidly absorbed (half-life, 15 min). Naproxen is FDA approved for children older than 2 years of age and is typically used for musculoskeletal pain. The dose is 10-15 mg/kg/day divided three times a day. Ketorolac is the only NSAID approved for IV use with an onset of action of approximately 30 minutes. Though dosing guidelines for children younger than 16 years of age have not been established, the generally accepted dose is 0.5-1.0 mg/kg to a maximum of 30 mg. Side effects include gastric irritation, decreased platelet function, renal insufficiency, and tinnitus.
Acetaminophen (Tylenol) has analgesic properties equivalent to aspirin but no anti-inflammatory properties. Acetaminophen does not cause gastric irritation or abnormal platelet function. Oral administered acetaminophen is rapidly absorbed (half-life, 2 hrs.). As with aspirin, rectal absorption is more erratic than oral absorption.
Opioid analgesics. In 1680, Sydenham wrote: "Among the remedies which has pleased the almighty to give to man to relieve his sufferings, none is so useful and efficacious as opium."
This dictum was true 300 years ago, and remains so today. In 1973, opioid receptors were discovered in nervous tissue, and a few years later the endogenous opioids were isolated and designated enkephalins and endorphins. All natural and synthetic opioids have been found to bind to opioid receptors that are found throughout the CNS with the highest concentration in regions known to be affiliated with pain pathways.
The selection of an opioid for a particular patient should address the following questions:
• How familiar am I with the drug (dose/duration/side effects?
• Do I want to give it orally, intramuscularly, intranasally, intravenously?
• Is this a 20-minute procedure or 20 hours worth of pain?
• What agent has worked best for this patient in the past?
• How experienced is my nursing staff with the drug?
• What monitors do I need?
• What is the cost?
The intravenous route should be used routinely for the administration of narcotics in the acute care setting. Intramuscular injections are painful and are often associated with a delayed onset of analgesic action. The intramuscular route is also difficult to titrate the dose, and absorption may depend upon the muscle used. Opioid analgesics are generally recommended when therapeutic doses of simple analgesics are unable to provide effective pain relief. However, opioids should be used initially as the analgesic of choice when moderate-to-severe pain is expected, rather than waiting until non-opioid analgesics fail. Contrary to common belief, opioids are often more easily tolerated than NSAIDs.
Because opioids do not have anti-inflammatory properties, it may be advisable to coadminister NSAIDs in conditions associated with inflammation. At equianalgesic doses, all opioid agonists exhibit similar degrees of decreased minute ventilation, hypotension, sedation, nausea, pruritus, and decrease in gastrointestinal motility with resultant constipation. Fortunately, for the majority of children, analgesia is reached prior to the onset of respiratory depression and most adverse reactions are reversible with naloxone (dose 0.1mg/kg IV/ETT/IO or 2 mg for children older than age 5 years or > 20 kg). A large interpatient variation in response is observed and analgesic doses should be titrated to effect.
Structurally related to morphine, codeine and oxycodone are weak opioid analgesics used for mild to moderate pain. Codeine is an oral medication that is approximately one-fourth as potent as morphine. At the usual doses of 0.5-1.0 mg/kg, it is well absorbed after oral administration, with peak levels 1.0-1.5 hours after ingestion. Codeine is metabolized in the liver to morphine. Combinations with acetaminophen provide more analgesia than each of the agents alone (e.g., Tylenol with codeine is available in different dosages:
• Elixir: 120 mg acetaminophen/12 mg codeine/5 cc
• Tylenol/codeine #1: 325 mg acetaminophen/7.5 mg codeine
• Tylenol/codeine #2: 325 mg acetaminophen/15 mg codeine
• Tylenol/codeine #3: 325 mg acetaminophen/30 mg codeine
• Tylenol/codeine #4: 325 mg acetaminophen/60 mg codeine
Codeine tends to be constipating and nauseating. For these reasons, many physicians recommend analgesics containing oxycodone (Percocet/Percodan), though a triplicate prescription is needed. The dose of oxycodone is 0.1 mg/kg.
Morphine, the gold standard of opioids, works via the opioid receptors in the CNS producing analgesia, drowsiness, euphoria, dose-related respiratory depression, reduction in peripheral vascular resistance, nausea, and pruritus. In cases of more severe itching or the precipitation of wheezing, it may be necessary to switch to another agent with less histamine release such as hydromorphone. Morphine is more effective for continuous, dull pain, than for sudden sharp pain, though it may be a reasonable choice for procedures lasting more than 30 minutes. The recommended dose is 0.05-0.15 mg/kg and may be administered every 2-4 hours. The onset of action is less than 1 minute with a peak effect at 5-20 minutes and a duration of action of 2-7 hours. The long duration of action makes morphine a poor choice for short procedures, but it works well for burn debridement, post-reduction fracture pain, and gunshot wound pain. Morphine is formulated as a tablet, continuous release tablet (MS contin), parenteral, epidural or intrathecal agents.
Hydromorphone (Dilaudid) can be administered in parenteral or tablet form and is used for moderate to severe pain. It is 5-7 times more potent than morphine. Pain relief is attained within 5 minutes IV and 30 minutes orally and lasts from 3-5 hours. Hydromorphone has no active metabolites and, therefore, is an appropriate alternative opioid for patients with renal failure.
Fentanyl is a synthetic opioid that is 75-125 times more potent than morphine. The recommended dose is 1-3 mcg/kg. Its onset of action is within 30 seconds, peak effect 5-15 minutes, and duration of action 30-60 minutes. The drug’s rapid onset and short duration of action have made it the opioid of choice for short, painful procedures. It is very effective for conscious sedation especially in combination with anxiolytics. However, as will be presented later, respiratory depression is more likely to occur when fentanyl is coadministered with benzodiazepines. Fentanyl causes less cardiovascular instability and histamine release than Morphine and is, therefore, safer for children who have hypovolemia, congenital heart disease, asthma, or head trauma. Apnea, bradycardia, chest wall, and glottic rigidity occur primarily with rapid infusion and high dosing (> 5 mcg/kg) of fentanyl. However, such effects can occur at any dose and may be reversed with naloxone, though reversal of chest wall and glottic rigidity may require neuromuscular blockade. Fentanyl is available in a raspberry flavored "lollipop" (Oralet) that can be very useful for patients undergoing burn debridement or fracture reduction. The dose of this formulation is 10-15 mcg/kg not to exceed 400 mcg and is available in 200, 300, and 400 mcg lozenges. It is not recommended for children younger than 2 years of age or weighing less than 15 kg. Onset of action is slightly longer at 5-15 minutes, and the duration of action is 1-2 hours. The incidence of emesis has consistently exceeded 30% and may limit its acceptability.
Alfentanyl is an analog of fentanyl that is five times less potent and has one-third the duration of action of fentanyl. Alfentanyl has the same adverse effect profile as fentanyl and works best for 20-30 minute procedures. The usual IV dose is 5-20 mcg/kg administered slowly.
Meperidine (Demerol), the most commonly used narcotic in the ED, is another synthetic opioid that is 10 times less potent than morphine. Unlike morphine, meperidine is a direct myocardial depressant. It is metabolized in the liver to normeperidine, a chemical that has CNS stimulant activity. Seizures, agitation, and myoclonus have been attributed to normeperidine, particularly in patients with renal insufficiency. Meperidine does not offer any benefits over the use of other opioids and it is not recommended when multiple doses may be needed or in children with epilepsy.
Nalbuphine (Nubain) and butorphanol (Stadol) are synthetic opioid agonist-antagonists. Because of their mixed actions, these drugs can be used to limit problems associated with pure agonists such as respiratory depression, nausea, and pruritus without decreasing the quality of pain relief. Nalbuphine and butorphanol exhibit a "ceiling effect," meaning a maximal beneficial effect is achieved no matter how high the dose offered. This ceiling effect makes nalbuphine and butorphanol safer drugs, proven effective for moderate pain. Nalbuphine dosing is the same as morphine, and it has an onset of action of 2-3 minutes and a duration of activity of 3-6 hours. Nasal administration of butorphanol provides a convenient alternative; although its onset of action is slower, the analgesic effect lasts longer than IV administration. Because each spray contains 1 mg of butorphanol, sprays cannot be used in children weighing less than 30 kg. These drugs should not be administered to patients chronically receiving opioids because acute withdrawal symptoms may be precipitated.
Other Agents. Ketamine is a phencyclidine derivative that produces dissociative anesthesia and amnesia. It can produce a trance-like state in which the child may appear awake in the presence of significant analgesia. The eyes will remain open with a nystagmic gaze. Ketamine is an attractive agent for pediatric procedures because it produces effective analgesia usually with minimal effects on cardiorespiratory function. It is effective when administered orally, IM, or IV. The recommended dose is 1-3 mg/kg IV. Ketamine is available only in a parenteral solution and must be mixed in a sweet syrup for oral administration. Ketamine has a rapid onset and a relatively short duration of action. Ketamine may increase intracranial pressure and cause vivid auditory, visual, and tactile hallucinations upon emergence from sedation, especially in children older than 10 years of age and females. Potential side effects also include increase salivation, laryngospasm, increased blood pressure, and nausea/emesis. Depression of myocardial function and apnea may occur at high doses. Unlike narcotics, there is no reversal agent available for ketamine and clinicians must be prepared to promptly respond if any of these problems occur. Management of laryngospasm may range from administration of oxygen and suctioning to BVM ventilation to the administration of paralyzing agents to facilitate intubation. A desirable effect of ketamine is bronchodilation, making this a good choice for the management of the airway of a child with asthma. To prevent hallucinations upon emergence from sedation, a benzodiazepine, such as midazolam, is often coadministered with ketamine. Emergence reactions may also be minimized by reduced verbal and tactile stimulation during recovery and using calm verbal reassurance. Atropine 0.01 mg/kg or glycopyrrolate 4 mg/kg is recommended to alleviate salivation. Ketamine should not be used in children with preexisting psychosis, children with upper airway infections, intracranial hypertension, glaucoma, acute globe injury, systemic hypertension, or children younger than 3 months of age.
Nitrous oxide is an inhaled sedative analgesic. It is administered by a demand valve face mask in a 50:50 mixture with oxygen and provides the following benefits: 1) rapid onset of action (4 min); 2) safety (no respiratory depression); 3) ease of administration; 4) short duration (effects gone within 5 minutes of discontinuation); and 5) inexpensive (though delivery system cost $3000). Since a cooperative child is a necessary component (in order to use the demand valve), it is most effective in children older than 8 years of age. Several studies have shown that nitrous oxide provides effective, safe analgesia in more than 80% of patients with moderate to severe pain. It is most effective with constant, dull, aching pain as opposed to brief, intense pain. Because it is highly diffusible, nitrous oxide can accumulate in enclosed body cavities, such as the middle ear or bowel, and potentially causes perforation; nonetheless, for brief use, it is very safe. Problems such as nausea, vomiting, and room contamination (scavenger system is needed) may complicate its use. It is contraindicated in children with an ileus, bowel obstruction, or pneumothorax.
Local Anesthetics. Local anesthetics block nerve conduction by decreasing neuronal membrane permeability to sodium preventing depolarization. Long the mainstay of pain relief in the ED, local anesthetics provide excellent pain relief with minimal concerns over airway and cardiovascular compromise. Because these drugs act locally, they must be administered at or near the desired site of action. Local anesthetics are tertiary amines and are classified as amides or esters. The esters (tetracaine, procaine, cocaine, benzocaine) are metabolized by cholinesterase. Since infants up to 6 months of age have less than half of the adult levels of this enzyme, clearance of this class of anesthetic may be reduced and the effects may be prolonged. Allergic reactions to ester local anesthetics occur because this class can stimulate IgE antibodies. The liver metabolizes amides (lidocaine, bupivacaine, prilocaine). Since infants younger than 3 months of age have reduced hepatic blood flow, this class of anesthetic remains unmetabolized.
Since most local anesthetics are acidic and, therefore, cause pain on injection, the addition of sodium bicarbonate to the local anesthetic (1MEq:9 ml of lidocaine) will reduce the injection pain. Epinephrine (1:200,000) also can be added to local anesthetics to prolong the nerve blockade, provide vasoconstriction (i.e., contraindicated in regions supplied by terminal arteries—digits, penis, nose, and pinna), and reduce systemic absorption. Systemic toxicity of local anesthetics can cause CNS excitation ranging from mild anxiety to convulsions, coma, and death which can be avoided by limiting dosage to recommended amounts and avoiding IV injection.
Lidocaine is used primarily for minor procedures (5 mg/kg without epinephrine and 7 mg/kg with epinephrine). With local infiltration, lidocaine has a rapid onset (1 minute) and a duration of action of 90 minutes. To lessen the pain of injection, the slow administration of warm medication and a small gauge needle (27 or 30) should be used. Bupivacaine (1.5 mg/kg without epinephrine and 3 mg/kg with epinephrine) is a longer acting (up to 6 hours) local anesthetic that has a greater potential for toxicity and is often unnecessary for most minor procedures.
Tetracaine (0.5%), adrenaline (1:2000), and cocaine (11.8%), or TAC, is a topical mixture that is effective for laceration repair. Hegenbarth et al found TAC alone to be sufficient in 89% of patients with scalp and facial wounds, and supplemental local anesthesia was required in 57% of patients with extremity wounds.24-27 A mixture of lidocaine (4%), adrenaline (1:2000), and tetracaine (.5%) may be as effective as TAC but has less risk of toxicity and lower cost. Other alternatives to TAC include: 1) prilocaine/phenylephrine, 2) tetracaine/phenylephrine, 3) bupivacaine/norepinephrine, and 4) lidocaine/epinephrine. The application is painless, and the wound isn’t distorted while anesthesia lasts approximately one hour. It is most effective when applied via a saturated cotton ball (not gauze) for 20 minutes prior to the procedure. Blanching of the skin usually indicates adequate anesthesia, although if the wound is not sufficiently anesthetized, further anesthesia should be induced by lidocaine infiltration, never a second application of TAC.
Significant problems with TAC include hallucinations or seizures, especially in conjunction with inadvertent application to mucous membranes or application to large abraded or burned skin. TAC is contraindicated in children with underlying convulsive (not benign febrile convulsions) or cardiac dysrhythmic disorders.
EMLA is a cream containing 2.5% lidocaine and 2.5% prilocaine. It provides topical anesthesia lasting up to two hours and is useful for IV catheter insertions, arterial punctures, and lumbar puncture. The cream is applied to intact skin with an occlusive seal and allowed to remain for at least one hour. Again, this medication should not be applied to mucous membranes or open wounds, and it is not approved for infants younger than 1 month of age because they are more susceptible to the development of methemoglobinemia. The use of EMLA in the ED is currently limited because of the time required for application. Its usage may be increased, however, if consideration is made at the time of triage.
Regional Blocks
Regional anesthesia is useful when a child is at increased risk of complication from general anesthesia or conscious sedation is associated with increased morbidity and mortality (e.g., children with neuromuscular, cardiac, or significant pulmonary disease). This approach is also useful in emergency situations when the child has a risk of aspiration.
Digital Nerve Block. Indications. Anesthesia of fingers and toes for surgical procedures (drainage of a felon, laceration repair, etc.)
Procedure. Thoroughly clean the planned puncture sites on the medial and lateral aspect of the finger with Betadine. Use a 25 gauge needle attached to a 5 cc syringe filled with 1% lidocaine (without epinephrine). Insert the needle from the dorsal aspect of the finger volarly until resistance by the palmar skin is felt. Instill 1 cc of lidocaine to block the palmar digital nerve. The needle is withdrawn, and 0.5 cc of lidocaine is instilled just deep to the point of entry to block the dorsal nerve. The needle is then withdrawn and the procedure repeated on the other side of the digit. (See Figure 3.)
Wrist Block. In order to gain anesthesia to the entire hand to facilitate laceration repair, debridement of burns, reduction of hand fractures, or foreign body removal, it is necessary to block the median, radial, and ulnar nerves.
The median nerve at the level of the proximal wrist crease courses superficially to lie between the more medial tendon of the flexor carpi radialis and the immediately radial tendon of the palmaris longus. Locate the two tendons by having the patient make a fist and flex the wrist. Clean the area with Betadine. Insert a 25 gauge needle at the level of the proximal skin crease perpendicular to and between the two tendons and inject 2-3 cc of 1% lidocaine. Two major branches of the ulna nerve at the level of the wrist—the palmar and the dorsal branches—must be blocked. The palmar branch is located between the ulnar artery and the flexor carpi ulnaris tendon, which is located at the ulna styloid process. The patient should flex and ulnarly deviate the wrist to locate the tendon. Insert a 25 gauge needle at the level of the proximal skin crease perpendicular to and between the tendon and the artery. Aspirate to prevent intravascular injection, then inject 2-3 cc of 1% lidocaine. The dorsal branch is blocked by infiltrating lidocaine subcutaneously, starting at the site of the palmar branch block and continuing around to the mid dorsum of the wrist. Wait 15 minutes for anesthesia. The radial nerve is located superficially at the radial aspect of the wrist. Insert a 25 gauge needle into the subcutaneous tissue lateral to the radial artery at the proximal flexor wrist crease. The tissue is infiltrated in a semicircular fashion around to the midportion of the dorsum of the wrist. Wait 15 minutes for anesthesia. (See Figure 4.)
Intercostal Nerve Block. This is a useful technique for providing analgesia to patients suffering from fractured ribs and to facilitate chest tube insertion. The intercostal block can be done at the level of the posterior, mid, or anterior axillary lines. Roll the skin superiorly over the rib and insert a 22 or 23 gauge needle, contacting the rib selected. Release the skin allowing the needle to slip to the upper surface of the selected rib and aspirate, observing for air or blood. If the aspiration is negative, 3 cc of lidocaine is injected. To achieve adequate analgesia, three intercostal nerves must be blocked for each rib (one above and one below each rib selected). The risks associated with this procedure include intravascular injection and pneumothorax.
Ankle Block. In order to provide anesthesia to the foot, there are five nerve blocks at the level of the ankle: the posterior tibial, anterior tibial, superficial peroneal, saphenous, and sural. The posterior tibial nerve is located behind the posterior tibial artery. Using a 25 gauge needle, a skin wheal is raised behind the artery, and the needle is advanced perpendicular to the skin. Paresthesia in the sole indicates that the needle is in proper position at which time 3-5 cc of lidocaine is instilled. The anterior tibial nerve is located between the anterior tibial muscle and the extensor hallucis longus tendon at the level of the malleoli. The needle is inserted just medial to the extensor hallucis longus tendon, which is located by dorsiflexion of the great toe. When paresthesia is elicited in the lateral aspect of the great toe, 3-5 cc of lidocaine is instilled. To block the superficial peroneal and saphenous nerves, a circumferential injection of 3-5 cc of lidocaine is made at the level of the superior border of the malleoli. The sural nerve is blocked by instilling 3-5 cc of lidocaine subcutaneously posterior to the distal fibula. (See Figure 5.)
Conscious Sedation
The goal and the American Academy of Pediatric definition of conscious sedation (CS) is a depressed level of consciousness, resulting in a cooperative and comfortable patient who remains responsive to verbal and physical stimuli, maintains protective airway reflexes, and independently maintains a patent airway. Physicians using sedation techniques must be capable of managing all aspects of patient sedation, including complications such as hypoventilation, airway obstruction, emesis, and cardiorespiratory arrest. Facilities must be appropriately equipped with oxygen, suction, resuscitation equipment, and drugs (including opiate and benzodiazepine reversal agents). Suitable candidates for sedation are healthy patients (i.e., classified as American Society of Anesthesiologists status I or II). Patients in categories III or IV require increased vigilance and are poor candidates for ED sedation.
The following is the classification of suitable candidates for conscious sedation according to the American Society of Anesthesiologists:
I. Healthy Patient;
II. Mild Systemic Disease—no functional limitation;
III. Severe Systemic Disease—definite functional limitation;
IV. Severe Systemic Disease that is a constant threat to life; and
V. Moribund Patient not expected to survive 24 hours with or without operation
In electing to use CS, the emergency physician must make a series of choices based upon the anticipated length of the procedure. The ideal agent(s) for CS is one that acts rapidly on the CNS in a titratable fashion with a duration of action long enough for the anticipated procedure, and is expeditiously eliminated to allow a timely and safe discharge from the ED. For simple, short procedures requiring minimal pain control (lacerations and lumbar puncture) administration of intranasal midazolam (0.3 mg/kg) or oral agents (oral midazolam 0.5 mg/kg or oral fentanyl lollipop) are preferred, especially when combined with local or topical anesthetics. Demerol/phenergan/thorazine (DPT) is an antiquated choice and suffers from oversedation (often greater than 6 hours), and is frequently associated with hypotension, respiratory depression, and dystonic reactions.28
Procedures that are extremely painful (orthopedic reductions, incision, and drainage of deep abscesses) require a deeper level of sedation that cannot be provided with transmucosal or oral agents. The safest and most effective method to achieve this is by IV titration of sedative/analgesic agents. Commonly used regimens include the administration of an IV sedative-hypnotic (midazolam or propofol or thiopental) combined with an IV analgesic (fentanyl or morphine). Ketamine is effective both IV and IM in reliable fashion, but as already noted, requires pretreatment with an antisialagogue and a benzodiazepine to prevent emergence reactions. A recent study has suggested that ketamine in combination with midazolam is more effective and safer than fentanyl/midazolam for orthopedic emergencies.41
Parents and patients should be informed about the risks and benefits of the CS process. Oral intake should be restricted prior to the elective procedure to minimize the risk of aspiration. If possible, procedures should be delayed to facilitate gastric emptying, since this may reduce the risk of aspiration (See Table 4.)
| Table 4. Restriction of Oral Intake Prior to CS | ||
| Age | Milk/Solids |
Clear Liquids |
| < 6 mo | 4 h |
2 h |
| 6-36 mo | 6 h |
2 h |
| > 36 mo | 8 h |
2 h |
Initial patient assessment should be followed by continuous oximetry, pulse and respiratory rate monitoring, and intermittent blood pressure recording. Patient monitoring should be continued by a dedicated patient observer (not intimately involved in the procedure) throughout the procedure and the recovery period. All conscious sedation medications should be drawn up in labeled syringes prior to onset of the procedure. Antagonist drug dosages should be calculated, but do not have to be drawn up prior to the onset of the procedure. Physicians intending to use any sedative or analgesic agent should be well versed in the pharmacokinetics and adverse effect profile of the chosen medication(s). The clinician should be able to provide basic and advanced life support, particularly in the management of the pediatric airway. Patients should not be discharged until the following criteria are met: 1) stable cardiorespiratory function; 2) normal airway patency and reflexes; and 3) recovery of presedation neurologic function. Use of antagonists, while hastening emergence, also accelerate the return of pain and anxiety and, thus, should not be used routinely.
Mechanical Approaches
Transcutaneous Electrical Nerve Stimulation. Transcutaneous Electrical Nerve Stimulation (TENS), as a nonpharmacologic adjunct, is an effective modality for reducing pain in children. It has been used for the treatment of reflex sympathetic dystrophy and sickle cell vaso-oclusive crisis. It should not be used as a substitute for other analgesic modalities (i.e., opiates) if these are required. TENS is delivered by a portable battery powered current generator that produces a nonpainful electrical stimulus delivered transcutaneously by two or more surface electrodes. The analgesic properties of TENS involve selective stimulation of myelinated afferent fibers, inhibiting A-delta and C fiber activity and, thereby, inhibiting nociception. All TENS units allow adjustment of the stimulus intensity. With proper instruction and practice, children can become independent in the use of TENS and, eventually, gain control over their pain. Patient acceptance is excellent, and there are minimal side effects. Controlled studies have shown TENS to be effective in 70-80% of acute pain suffers. Not enough literature exists in emergency medicine to define the use of TENS, but the potential exists.
Acupuncture. Acupuncture has been a treatment modality in traditional Chinese medicine since the 5th century. For those who practice allopathic medicine, it has been difficult to accept the idea that acupuncture could have any benefit. Acupuncture is useful in management of acute pain (e.g., dental procedures, sickle cell vaso-oclusive crisis, reflex sympathetic dystrophy, and migraine headache). Acupuncture analgesia is believed to be mediated by opioid peptides such as endorphins, and naloxone has been shown to block its analgesic effects.
Conclusion
Acute pain plays an important role for pediatricians and emergency physicians by aiding in the diagnosis or localization of an injury. However, no purpose is served by allowing a patient to endure this pain. Children can and should be adequately treated for their pain in the ED. It is important to keep in mind that they might not be aware that their pain can be relieved and, hence, will not request analgesia. Suffering children are confused and scared and they may view their injury as a punishment. It will be up to you, the treating physician, to address their pain. Many tools are available to decrease pain perception. Both psychologic and pharmacologic therapies must be tailored to each child, then continuously reassessed for efficacy. The key to safe and effective pain management is to start small, evaluate results, and titrate to the desired effect. The myths regarding pediatric pain management have been dispelled, and there is no reason to withhold analgesics. Emergency medicine physicians have the exciting and challenging opportunity to become leaders in providing the clinical management, education, and research on acute pain.
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Physician CME Questions
9. A premature infant born 5 days ago at 32 -weeks gestation requires a PDA ligation. Which of the following is true regarding the use of analgesia in the age group?
a. The infants immature neurologic system is incapable of sensing and appreciating pain; therefore little attention need be focused on pain management.
b. When using local anesthetics, the clinician does not have to address any special considerations regarding this group of medications.
c. Ketamine would be the preferred analgesic choice.
d. The careful use of narcotic analgesics often started in small doses and titrated to effect is often safe and effective.
10. Which of the following should be considered for a child undergoing a painful procedure?
a. The child should be offered details appropriate for the developmental age of the child regarding the procedure and the method(s) used for pain alleviation.
b. The parents should be encouraged to leave the examination room while the procedure is in progress.
c. Other than administering pain medication to the child, the medical staff have little else to offer the child to alleviate pain.
d. The child should be placed in a papoose board restraint.
11. A 6-year-old asthmatic child presents to the ED with a fracture needing close reduction. A preferred choice for offering this child conscious sedation is:
a. fentanyl/midazolam.
b. morphine/midazolam.
c. nubain alone.
d. ketamine/atropine/midazolam.
12. A child with a 3 cm laceration reports being allergic to novacaine. A good local anesthetic choice is:
a. tetracaine/adrenaline/cocaine.
b. EMLA.
c. topical lidocaine/adrenaline/tetracaine.
d. infiltrate the wound with lidocaine alone.
13. A reason that EMLA is not widely use in the ED is:
a. it is particularly effective in the alleviation of pain.
b. fear of sensitizing the child to lidocaine.
c. too expensive.
d. the process of applying the medication is often not conducive to the acute management of sick and injured children.
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