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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

Moderate Sedation/Analgesia Moderate Sedation/Analgesia
„ Previously called “conscious sedation” „ Drug induced depression of consciousness but
still have purposeful response to verbal
but now more appropriately “procedural
commands alone or with light tactile stimulation.
analgesic and sedation”
„ No interventions required maintaining patent
„ Required for invasive painful airway or ventilations. CV function usually
procedures such as fracture reduction adequate
„ SpO2 monitored continuously. Continuous „ SpO2 continuously. Continuous visual
visual monitoring by person not involved in monitoring of Respiration. HR and B/P
procedure. HR, RR, B/P prior to procedure monitored at least every 15 min. Response
and as needed during. every 2-3 minutes. Oxygen at hand.

Deep sedation/Analgesia General Anesthesia

„ Depression of consciousness where patient „ Drug induced state where patient cannot
cannot be easily aroused by verbal or noxious be aroused by painful stimuli.
stimuli but respond purposefully to repeated or
painful stimulation. „ Usually impairs protective airway
„ Protective airway reflexes and ventilation may reflexes and spontaneous ventilation.
be compromised. CV function usually May impair CV function.
maintained „ HR, RR, SpO2 monitored continuously.
„ SpO2 and HR continuously. Continuous visual B/P every 2-3 minutes or continuously.
monitoring of Respirations. B/P monitored
„ Supplemental oxygen required.
every 5 min. Supplemental oxygen given.

Venupunctures, IV starts, lumbar

Laceration Repair
punctures& immunizations
„ Topical Anesthetics „ Topical Anesthetics-soak gauze and hold
– AMETOP (amethocaine gel)-30 minute action, to laceration for 10 min
less vasoconstrictive effects, some local
– TAC (tetracaine, adrenalin (epinephrine),
– EMELA (lidocaine, prilocaine)-45 to 60 min
action, some vasoconstriction (approved for
– ELA-Max or Maxilene -liposomal lidocaine-30 – LET (lidocaine, epinephrine, tetracaine)
minute action, less erythema • Safer than TAC

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

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

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

Nitrous Oxide- “Laughing Gas” Nitrous Oxide- “Laughing Gas”
„ Antiolytic, analgesic, amnesic
„ Inhaled mixed 1:1
„ Give for 3-4 minutes prior to procedure with oxygen
„ Often augmented with local anesthetic, „ Self administered
narcotics, or acetaminophen by demand valve,
„ Recover with oxygen scented mask, or
whistle device

Nitrous Oxide- “Laughing Gas” Nitrous Oxide- “Laughing Gas”

„ Best effects in children over 3 years as „ Used extensively in UK, Europe, &
more compliant with inhalation technique Australia by non-Anesthesiologists
„ Not for use with asthma, pneumothorax,
head injury or ocular problems „ Minor side effects only-nausea, vomiting,
„ Worker protection required hallucinations, euphoria, restlessness

Putting it all together:

Case Study
„ Tommy, a 8 year old boy, arrives at
„ Airway, Breathing, Circulation
your ER with his father. He is holding
his left wrist against his body. Tears are „ Disability-alert and orientated, obvious
rolling down his cheeks and he looks deformity of Left wrist but pulse, color,
pale. His parents tell you they think his sensation good. Tommy crys out
wrist is broken. He fell while whenever limb moved or touched. He
snowboarding down the neighborhood rates pain 10 out of 10 with movement of
hill with his friends. How do you limb and 7 out of 10 when limb not
proceed? moved.

Focused history: AMPLE Non-pharmacological Methods

„ No allergies, no regular medications, no „ Involve Tommy & his Dad in care

complex medical history, last ate at – Explain what is going to happen
noon (2 hrs ago), slipped backward on „ Support limb/limit movement-let child
snowboard and put hand down for continue to splint. Remove clothing after
support, was wearing helmet. Walked pain medication given
home about 2 blocks. Incident
„ Elevation
happened about 20 minutes ago.
„ Cold packs

„ Start IV with topical anesthetic „ Give Morphine as ordered as soon as IV in
(prior to removing clothing, x-ray &
– Examine for ease of IV start
extensive exam)
– Get history from child if has had IV
„ Advocate for gentle examinations, allowing
– Give Tommy choice as IV with or without child to move and position limb
topical preparation as fracture pain rated as
„ Give Morphine regularly until wrist
reduction/casting complete
„ Nitrous oxide administration for IV start „ Teach family to manage pain at home with
ibuprofen/acetomenophren , elevation, cold
packs, sling & to return if pain uncontrolled

What can we do to What can we do to

make it better? make it better?
„ Anticipate the procedure and advocate „ Treat pain first-anxiety often comes from being
for the child! in pain
„ Differentiate between analgesic & „ Provide maximum treatment for the first
sedation procedure to build trust
„ Attend to environmental comfort-temp, „ Combine pharmacological and non-
lighting, too many people pharmacological techniques for synergistic
„ Let parents/caregiver have choice about
„ Teach families how to assess & manage pain
being present and show them how to following procedure

„ 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)
„ 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
„ 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.