Pain in children, management in the ED

• 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 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:

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

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).

• 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.

- 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 

Approved by Drugs and Therapeutics Committee: May 2008