Kids in pain. Chris Lipp PGY 3 - Vic.

Transcription

1 Kids in pain Chris Lipp PGY 3 - Vic.

2 No disclosures

3 Outline Objectives Case based learning Assessment of pain Management do s and don ts Topical Oral Intranasal IV Special circumstances Audience feedback

4 Objectives Review acute pain pathophysiology Explore pain assessment: neonates teens Describe indications and contraindications to topical anesthetics Review optimal oral analgesics for kids Emphasize the effectiveness of intranasal analgesia

5 Why Why do we care? does it hurt?

6 Uptodate 2015 Sosnowski M, Lebrun P, Fodderie L. Anesth Clin North Am 1992; 10:211.

7 ?% < 50% *kids less likely to receive adequate analgesia than adults*

8 ...why treat pain? procedure duration LOS slower healing emotional trauma patient parents siblings suffering Long-term: Δ pain processing hyperalgesia up-winding of pain avoidance of heightened sensitivity to medical care fear of healthcare evaluation EM Cases July 2015

9 How & What 4 Cases to assess? can you do about it?

10 1) 3 mo old with leg pain 2) 12 mo old with crying 3) 10 yo with deformity to arm 4) 5 yo with laceration

11 Case 1 3 month old not moving her leg looks well, afebrile withdraws to touch and cries with movement of right leg no soft tissue trauma or NAT

12 Case 1 how to assess pain in the neonate-toddler? how to treat?

13

14 Behaviour-observation scales newborn - toddlers

15 Not perfect No observational tool is consistently superior to another 1. staff training 2. time

16 Treatment options? 1. tylenol 2. advil brutane* 5. po codeine 6. po morphine 7. iv morphine 8. IN fentanyl 9. IN midazolam 10. IM / IV / IN Ketamine

17 What s fast, safe & effective?

18 IN fentanyl vs. IV morphine Three RCTs (n=313) reduction of pain at 10 mins INF = IVM at 20 mins no adverse events (opiate toxicity, or death) *all studied acute pain in children > 3 yrs old

19 33% intranasal fentanyl easy to implement

20 treatment plan intranasal fentanyl* 1.5 mcg/kg then casting/splinting

21 IN pearls: pre-administration max vol. per nare ml post-administration

22 Honourable mentions

23 Other tools available IN Ketamine? optimal dosing 0.5 mg/kg - 3 mg/kg PICHFORK study Nitrous Oxide Site dependent IN Midazolam (0.5 mg/kg) Sucralose & warmth

24 Case 2 12 mo. old bounce-back google images

25 not working tylenol and advil ain t cutting it

26 Toddler with a bad ear-ache uptodate 2015

27 Treatment options? 1. tylenol 2. advil brutane 5. po codeine 6. po morphine 7. topical anesthetics 8. IM / IV / IN Ketamine

28 topical analgesics? Kids > 3 yrs topical ear drops may work 2% lidocaine herbal drops

29 help the parents sleep! Topical lidocaine 2% applied PO Advil at **10 mg/kg** re-examined non-toxic no other injuries / focal findings discharged happily ever after

30 ? what about codeine? requires CYP2D6 for metabolism morphine 10 % >>>>> & <<<< anoxic brain injury & death the FDA and European Medicines Agency: advise AGAINST its use in kids < 18 yrs due to CYP2D6 polymorphism

31 No codeine for kids <12

32 Case 3 11 yo w. Downs rugby tackle arm pain How to assess his pain?

33 Self-reporting >~3-8 yrs FACES >~8-11 yrs VA / > 11 yrs Numerical rating Descriptive

34 How do you assess pain in: non-verbal & neurologically impaired children?

35 Cues that a non-verbal child may be in pain 1. Non-verbal 2. Vocalizations 3. Inconsolability 4. Movement 5. Atypical *** ASK FAMILY! *** 1. grimacing 2. crying, moaning arching, stiffening 5. withdrawn, laughing, lack of facial expression

36 case resolution moderate pain IN fentanyl 1.5 mcg/kg (max dose) then walked to radiology AIN intact EMLA/AMETOP patch IV morphine 0.1 mg/kg To the OR for fixation

37 Case 4 5 yo F. cut to forehead anxious and crying as you approach

38 how to manage this anxious patient? Non-pharmacologic distractions child-life parent s voice & lap iphone music TV toys Way of making the dermabond less painful? # apply LET to wound* BEFORE dermabond application

39 RECAP

40 Summary - pain assessment Neonates Toddlers Preschool School age Adolescents Non-verbal NI FLACC Scale FACES Revised Visual Analog scale Caregiver cues observational

41 vital signs pediatric pain assessment

42 Summary - when to use topical anesthetics EMLA (eutectic mixture of local anesthetics) Amethocaine 4% gel - 30 mins faster onset Pre-IV/IM insertion* LET/LAT (lidocaine, epinephrine, tetracaine) Pre-dermabond application Pre-local anesthetic application* 2 % Lidocaine?> 3 yr old with acute OM

43 Summary - analgesics treat pain early and aggressively! don t shy away from PO morphine stop using codeine time for intranasal fentanyl midazolam & ketamine - IV morphine...if you have an IV NO CODEINE

44 PO Morphine 0.3 mg/kg IN Fentanyl 1.5 mcg/kg

45 References Uptodate EM Cases July 2015 TREKK.ca SGEM #123 & RANThony #3 An Intervention to Improve Pain Management in the Pediatric Emergency Department.[Article] Pediatric Emergency Care. 28(6): , June

46 Thanks: Dr. Simran Grewal

47 Comments? Ketamine experiences*? *not your personal experiences please