When do we inflict pain?

Procedural Pain Management „ Needle Pokes -Venupuncture,IV starts

in Children „ Lumbar punctures
„ Fracture examination,reduction, casting
Janlyn Rozdilsky „ Laceration repair
RN MN CNCCP(C) „ Dressing changes
Clinical Nurse Educator
PICU Royal University Hospital
„ Tube Insertion-Foley catheter,Gastric
Saskatoon, Sask tube, endotracheal tube

Key Definitions
„ Analgesic-reduces or eliminates the
Most analgesics have some
perception of pain sedative properties, but many
– ex: opiods, NSAIDS sedatives lack analgesic
„ Sedation-reduces awareness: it does effects.
not relieve pain.
– May causes hypnosis (sleep)
– ex: benzodiazapines
„ Amnesic-inability to remember an event
or experience

Minimal Sedation –Antiolysis

Levels of Procedural
Analgesic/Sedation „ Does not effect respiratory or
cardiovascular functions
„ Patients respond to verbal commands
but may have impaired cognitive
function and coordination

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 Moderate Sedation/Analgesia
„ Previously called “conscious sedation”
but now more appropriately “procedural
analgesic and sedation”
„ Required for invasive painful
procedures such as fracture reduction
„ SpO2 monitored continuously. Continuous
visual monitoring by person not involved in
procedure. HR, RR, B/P prior to procedure
and as needed during.
Deep sedation/Analgesia
„ Depression of consciousness where patient
cannot be easily aroused by verbal or noxious
stimuli but respond purposefully to repeated or
painful stimulation.
„ Protective airway reflexes and ventilation may
be compromised. CV function usually
maintained
„ SpO2 and HR continuously. Continuous visual
monitoring of Respirations. B/P monitored
every 5 min. Supplemental oxygen given.
Venupunctures, IV starts, lumbar
punctures& immunizations
„ Topical Anesthetics
– AMETOP (amethocaine gel)-30 minute action,
less vasoconstrictive effects, some local
erythema
– EMELA (lidocaine, prilocaine)-45 to 60 min
action, some vasoconstriction (approved for
immunizations)
– ELA-Max or Maxilene -liposomal lidocaine-30
minute action, less erythema
Moderate Sedation/Analgesia
„ Drug induced depression of consciousness but
still have purposeful response to verbal
commands alone or with light tactile stimulation.
„ No interventions required maintaining patent
airway or ventilations. CV function usually
adequate
„ SpO2 continuously. Continuous visual
monitoring of Respiration. HR and B/P
monitored at least every 15 min. Response
every 2-3 minutes. Oxygen at hand.
General Anesthesia
„ Drug induced state where patient cannot
be aroused by painful stimuli.
„ Usually impairs protective airway
reflexes and spontaneous ventilation.
May impair CV function.
„ HR, RR, SpO2 monitored continuously.
B/P every 2-3 minutes or continuously.
„ Supplemental oxygen required.
Laceration Repair
„ Topical Anesthetics-soak gauze and hold
to laceration for 10 min
– TAC (tetracaine, adrenalin (epinephrine),
cocaine)
– LET (lidocaine, epinephrine, tetracaine)
• Safer than TAC
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 Laceration Repair
Laceration Repair
„ Skin Adhesives „ Suturing
– Dermabond (skin glue) – Needle size-smaller than 25 gauge
– Useful for small lacerations especially face as – Buffer lidocaine with Sodium Bicarb in 9:1
no stitch marks. ratio
– Covers wound so no dressing needed. Has to – Warm local anesthetic
be held for 60 seconds. – Inject slowly
– Polysporin weakens bond but can shower – Inject through wound edges rather than
intact skin

Medications
„ Always given on a “per/kg” basis
„ Two persons required-one to perform
procedure, one to monitor patient and
intervene as required
„ Airway management supplies at bedside
(suction, oxygen, manual ventilation
unit)
„ May require IV fluids prior to procedure
if prolonged fasting
Medications
„ “Administrator of the medications must
have an understanding of the drugs,
ability to monitor the patient’s response
to treatment given, and the skills
required to intervene and manage all
potential complications”
– Dr. Vicki Cattell, Peds ER, RUH, Saskatoon

Midazolam (Versed) Midazolam

„ Antiolytic, amnesic „ Adverse Effects-resp. depression, ataxia,
„ Dose: PO 0.25-0.75 mg/kg paradoxical excitation, hypotension,
Subling 0.25-0.3 mg/kg myoclonic seizure-like activity
IV 0.05-0.15 mg/kg
PR 0.5-0.75 mg/kg
„ Antagonist: Flumazanil
„ Avoid nasal route – Dose 0.01 mg/kg up to 1 mg
„ Peak 3-5 min IV, 10-20 min other routes – Onset 1-2 minutes Duration 1 hour
– Observe at least 2 hours for re-sedation
„ Duration PO/PR 60 min, IV 20-60 min

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 Narcotics Morphine
„ Narcotics remain gold standard for „ Dose: 0.05-0.1 mg/kg
treatment of moderate to severe pain „ Onset: 5-10 minutes
„ Duration: 2-4 hrs.
„ Do not give IM!! „ Safe medication in most children.
„ May have some hemodynamic compromise
„ Use for invasive & painful procedures in hypotensive child due to histamine
setting fracture, burn dressing, chest release
tube, intubation

Fentanyl Other Narcotics

„ 50-100 times more potent than morphine with
less sedation, less respiratory depression & „ Codeine
less hypotensive side effects – has to be converted
„ Dose: 1-2 mcg/kg IV – Ineffective in 1/3 of people
„ Onset: 2-3 minutes – No IV form
„ Duration 20-60 minutes „ Remifentanyl-very short acting so useful
„ Rarely produces chest wall rigidity requiring for short, painful procedures
assisted ventilation – ex: fracture reduction
„ Consider continuous infusion if using for more „ Sufentinil-used primarily in OR
than procedure

Narcotic Reversal-Naloxone Ketamine

„ Provide respiratory assistance first, then
consider if reversal needed.
„ Titrate Narcan in small aliquots (0.001-0.01
mg/kg) until respiratory efforts satisfactory
„ Complete, sudden reversal will result in acute
pain that can trigger sudden hypertension and
pulmonary edema
„ May have to repeat doses as not as long
acting as some narcotics
„ Dissociate anesthetic agent providing
analgesia, sedation, and amnesia
„ Dose 1-2 mg/kg IV
„ Duration 15-20 minutes
„ Use with atropine to diminish oral
secretions & small dose Midazolam to
reduce hallucinations
„ Contraindicated with brain
injury/inflammation

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 Nitrous Oxide- “Laughing Gas”
„ Antiolytic, analgesic, amnesic
„ Give for 3-4 minutes prior to procedure
„ Often augmented with local anesthetic,
narcotics, or acetaminophen
„ Recover with oxygen
Nitrous Oxide- “Laughing Gas”
„ Best effects in children over 3 years as
more compliant with inhalation technique
„ Not for use with asthma, pneumothorax,
head injury or ocular problems
„ Worker protection required
Putting it all together:
Case Study
„ Tommy, a 8 year old boy, arrives at
your ER with his father. He is holding
his left wrist against his body. Tears are
rolling down his cheeks and he looks
pale. His parents tell you they think his
wrist is broken. He fell while
snowboarding down the neighborhood
hill with his friends. How do you
proceed?
Nitrous Oxide- “Laughing Gas”
„ Inhaled mixed 1:1
with oxygen
„ Self administered
by demand valve,
scented mask, or
whistle device
Nitrous Oxide- “Laughing Gas”
„ Used extensively in UK, Europe, &
Australia by non-Anesthesiologists
„ Minor side effects only-nausea, vomiting,
hallucinations, euphoria, restlessness
Assessment
„ Airway, Breathing, Circulation
„ Disability-alert and orientated, obvious
deformity of Left wrist but pulse, color,
sensation good. Tommy crys out
whenever limb moved or touched. He
rates pain 10 out of 10 with movement of
limb and 7 out of 10 when limb not
moved.
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 Focused history: AMPLE
„ No allergies, no regular medications, no
complex medical history, last ate at
noon (2 hrs ago), slipped backward on
snowboard and put hand down for
support, was wearing helmet. Walked
home about 2 blocks. Incident
happened about 20 minutes ago.
Pharmacological
„ Start IV with topical anesthetic
– Examine for ease of IV start
– Get history from child if has had IV
– Give Tommy choice as IV with or without
topical preparation as fracture pain rated as
severe
„ Nitrous oxide administration for IV start
What can we do to
make it better?
„ Anticipate the procedure and advocate
for the child!
„ Differentiate between analgesic &
sedation
„ Attend to environmental comfort-temp,
lighting, too many people
„ Let parents/caregiver have choice about
being present and show them how to
help
Non-pharmacological Methods
„ Involve Tommy & his Dad in care
– Explain what is going to happen
„ Support limb/limit movement-let child
continue to splint. Remove clothing after
pain medication given
„ Elevation
„ Cold packs
„ Give Morphine as ordered as soon as IV in
(prior to removing clothing, x-ray &
extensive exam)
„ Advocate for gentle examinations, allowing
child to move and position limb
„ Give Morphine regularly until wrist
reduction/casting complete
„ Teach family to manage pain at home with
ibuprofen/acetomenophren , elevation, cold
packs, sling & to return if pain uncontrolled
What can we do to
make it better?
„ Treat pain first-anxiety often comes from being
in pain
„ Provide maximum treatment for the first
procedure to build trust
„ Combine pharmacological and non-
pharmacological techniques for synergistic
effects
„ Teach families how to assess & manage pain
following procedure
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 References
„ Annequin, D., Carbajal, R., Chauvin P., Gall O., et al. 2000. Fixed 50% nitrous
oxide oxygen mixture for painful procedures: A French survey. Pediatrics 105 (4)
http://pediatrics.aappublications.org/cgi/content/full/105/4/e47
„ Burnweit, C, Diana-Zerpa, J. A., Nahmad, M. H., Lankau C, A., et al. 2004.
Nitrous oxide analgesia for Minor pediatric surgical procedures: An effective
alternative to conscious sedation? Journal of Pediatric Surgery 39 (3) 495-499
„ Cattell, V. 2005, October. Pediatric Pain Management in the ER. Presentation to
Pediatrics 2005 Conference, Saskatoon.
„ Mattick, A. 2002. Use of tissue adhesives in the management of paediatric
lacerations. Emergency Medicine Journal 19, 382-385.
„ Prodedural Sedation 2001. PALS Provider Manual . American Heart and Stoke
Foundation
„ Razzi, M. 2006, Februrary. Pediatric Anesthesia: What’s New? Unpublished
presentation at PICU Education Day, Royal University Hospital, Saskatoon
„ Young, K. D. 2005. Pediatric procedural pain. Annals of Emergency Medicine 42
(2) 160-171.