DISCLOSURE • I have NO financial conflicts to disclose
OBJECTIVES • Review anatomical and physiologic differences unique to the pediatric population • Explain developmentally appropriate strategies and tools for pediatric pain assessment • Describe nonpharmacologic and pharmacological pain management options for pediatric patients
PEDIATRIC PATIENTS
PAIN MANAGEMENT AND PROCEDURAL SEDATION • Tailor medication to each patient – Past history, weight, depth of sedation, procedure being performed
• Understand actions, indications, and contraindications of common medications • Initial doses with frequent reassessment and titration to adequate sedation level to minimize risks • Anticipate and prepare for common complications
PEDIATRIC PATIENT EMS CALL
PEDIATRIC AIRWAY DIFFERENCES • • • •
Smaller Airway Large Tongue Epiglottis Larynx Position – C3/4 Pediatric – C4/5 Adult
• Large head compared to body • Anterior Airway
PAIN “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”
PAIN ASSESSMENT • Four pain scales validated and tested extensively – Wong Baker FACES – Faces Pain Scale and Revised – The Oucher Pain Scale
• Wong Baker FACES preferred by children • Anchor of smiling and crying may be a disadvantage causing confounding pain intensity *Tomlinson D, et al. A Systematic Review of Faces Scales for the Self-report of Pain Intensity in Children Pediatrics: 2010
HOW DO WE MANAGE PAIN AND PROVIDE PROCEDURAL SEDATION?
DISTRACTION • Child life specialists • Terminology or language easy for children to understand • Step by step explanation
DISTRACTION • Do NOT underestimate power of distraction
PHARMACOLOGIC AGENTS Sedation
Analgesia
Amnesia
Narcotics
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Benzodiazepines
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Etomidate
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Ketamine
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Propofol
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FENTANYL • • • • • • • •
Sedation, analgesia, NO amnesia Preferred due to faster onset of action and shorter recovery period No histamine release Available PO, IM, IV, IN Dose: 1-2 mcg/kg/dose Onset: 2-3 min Duration of action: 20-60 min Reversible with Narcan
FENTANYL ADVERSE EFFECTS • Respiratory depression dose and infusion rate-dependent • Hypotension • Skeletal muscular or chest wall rigidity – Neonates – Large doses >5-10 mcg/kg
• Increased respiratory depression when co-administered with midazolam
MIDAZOLAM • Sedative, amnesia, NO Pain • Preferred due to short duration compared to others • Reversible with Flumazenil • Dose – – – –
0.5-0.75 mg/kg PO 0.2-0.5 mg/kg IN 0.1-0.15 mg/kg IM 0.05-0.1 mg/kg IV
• Onset of action – – – –
PO 10-15 min IN 10-30 min IM 15-30 min IV 10-20 min
• Duration of action – PO/IN/IM 60-90 min – IV 45-120 min
Sedative Hypnotic, NO analgesia, NOT reversible Dose: 0.2-0.6 mg/kg IV Onset: 15-45 sec Duration of action: 3-12 min Recovery: 16, female, excessive noise or stimulation during recovery, personality disorders, increased normal dreams
