Pain in children, management in the ED

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Objectives

  • Recognise pain in children and provide analgesia for moderate & severe pain within 20 minutes of arrival in the Emergency Department
  • In treating pain, attention should be paid to other factors distressing the child such as fear of unfamiliar environment and people, parental distress, people in uniforms, needle avoidance, fear of injury severity etc.

Scope

Patients presenting to the Paediatric Emergency Department. 

Audience

Medical and nursing staff in the Paediatric Emergency Department.

Introduction
  • Pain in children can be difficult to assess (for example the child may not appear distressed or have difficulty describing / admitting to pain). This can lead to pain being under-recognised, under-treated and treatment being delayed. Drug choice and dosage may also cause problems in those not used to treating children due to unfamiliarity.
Pain assessment
  • Pain assessment should be repeated frequently to ensure adequate response to any intervention.
  • In the Emergency Department of the Royal Hospital for Sick Children, it is the experience of the Triage Nurse that is used to gauge the severity of a child’s pain, based on their observation and feedback from parents.

For example:

 

No Pain

Mild Pain

Moderate Pain

Severe Pain

Behaviour

Normal activity 
No↓ in movement 
Happy

Rubbing affected area 
Decreased movement 
Neutral expression 
Able to talk/play normally

Protective of affected area 
↓movement/quiet 
Complaining of pain 
Consolable crying 
Grimaces when affected part moved/touched  

No movement or defensive of affected part 
Looking frightened 
Very quiet
Restless, unsettled 
Complaining of lots of pain Inconsolable crying   

Injury example*

 

Abrasion/small laceration Ankle sprain 
Minor head injury

Small burn/scald 
Undisplaced limb #
Fingertip injury 
Appendicitis

Displaced limb # # dislocation 
Larger burns/scalds Appendicitis 
Sickle crisis

* Example of injury is only intended as a guide – cases should be assessed on an individual basis

Algorithm for treatment of acute pain in children in the Emergency Department

If child is being admitted and is likely to need ongoing analgesia for moderate / severe pain, consider contacting pain relief nurse specialist (page 8133/ ext. 86920) or duty anaesthetist (page 8602).

Other ways to manage pain
  • Psychological strategies: involving parents, cuddles, child-friendly environment, and explanation with reassurance all help build trust. Also, distraction with toys, blowing bubbles, reading, portable DVD players or story-telling can help to alleviate pain.
  • Non-pharmacological adjuncts such as limb immobilisation for fractures and dressings for burns.
Guideline for using Intranasal Diamorphine

- to be used in conjunction with Emergency Department Pain Management guideline

Indications:

To be included as part of the first-line treatment of severe pain in a child (without IV access). 
For example, in children with pain secondary to:
 - Clinically suspected limb fractures
 - Painful/distressing burns

Contraindications:

  • Need for immediate IV access (use parenteral morphine)
  • Significant nasal trauma
  • Blocked nose or upper respiratory tract infection
  • Age < 1 year (or weight < 10kg)
  • General contraindications/sensitivity to diamorphine or morphine use
  • Significant head injury

Protocol:

  1. Weigh the child in kg, transfer to resuscitation area (if not already done), monitor O2 sats
  2. Prescribe diamorphine via intranasal route (in mg) based on child’s weight (see chart – round to nearest weight; final dose=0.1mg/kg) and use chart (below) to determine the volume of water to add to a 5mgdiamorphine ampoule. Mix well.
  3. Draw up 2 mls (0.1mg/kg)of the resultant solution into a 1ml syringe and discard the rest (following controlled drugs procedure)
  4. Gently tip child’s head and instill 1mlinto each nostril (total of 0.2mls in drops). Occlude the other nostril after each 0.1ml and ask the child to sniff.
  5. Don’t forget to give supplementary oral analgesia (if not contra-indicated) and that the child may need ongoing IV analgesia once the initial pain is controlled
  6. Intranasal diamorphine is usually effective within 5-10 minutes but allow up to 20 minutes for maximal pain control
  7. Continue 02 sats monitoring for 1 hour post administration. Analgesic effect lasts up to 4 hours. Providing the child is stable, they can be transferred elsewhere within the department for ongoing monitoring once diamorphine has been administered.

Guidelines for making up Intranasal Diamorphine Solution 

dilute 5mg of diamorphine powder with specific volume of sterile water 

Weight (kg)

Volume of sterile water to be added

Final dose in mg (in0.2mls)

10

1ml

1mg

11

0.9ml

1.11mg

12

0.85ml

1.18mg

14

0.7ml

1.43mg

16

0.6ml

1.67mg

18

0.55ml

1.82mg

20

0.5ml

2mg

25

0.4ml

2.5mg

30

0.35ml

2.86mg

35

0.3ml 

3.33mg 

40

0.25ml 

4mg 

≥50

0.2ml 

5mg 

Approved by Drugs and Therapeutics Committee: May 2008

Editorial Information

Last reviewed: 01 February 2015

Next review: 13 November 2019

Author(s): Joanne Stirling

Approved By: Clincial Effectiveness