Flicking through the tracks at EuSEM15 you might notice that there are several presentations – including mine – devoted to the management of pain and procedural sedation in children. And you might wonder why this particular topic deserves so much attention.
Estimates suggest that around 50% of attendances to the Emergency Department concern pain. With pain affecting around half of the patients we see, we must be pretty good at sorting it out, right?
Back in 1997, Pediatrics published a paper by Petrack and colleagues in which they had studied three separate EDs; an adult ED, a paediatric ED and a joint ED. They found firstly that children in pain receive analgesia less than adults and secondly that the difference was more profound in the combined adult/paediatric ED. But that paper was published 18 years ago – if we know about that, we must have done something about it by now – right?
In the UK the Royal College of Emergency Medicine has embraced the idea that children should receive analgesia in a timely manner and as such has set clinical standards; that analgesia should be provided in “severe pain” within 20 mins and the patient re-evaluated within 60 mins. There have been 6 iterations of a national audit of this standard, the most recent in 2011-2012. And the bad news – for us and for our patients – is that we are still barely managing to provide analgesia in moderate to severe pain in children. Nationally, only 5% of all audited children received adequate pain relief before arrival in the ED, 43% within 20 minutes of arrival, 57% within 30 minutes and 72% within 60 minutes of arrival. Even in severe pain only 53% received analgesia within 20mins of arrival in ED. And if we are actually reassessing we are not recording that in a way that could even be audited.
Pain is More than Nociception
Of course, managing pain in children is not easy. Pain is hard to measure. Many children are too young to give a numerical score – and many adults struggle with this too. There are other scales we can use but with something so subjective, it’s difficult to find a valid and reliable measure and I wonder if that’s why sometimes we don’t even try to record pain scores.
Pain is so much more than nociception and pain pathways; more complex than tissue damage causing neuronal firing. I bet you know someone who has more than one tattoo. People often describe the pain associated with tattoos as pleasurable; these people have chosen pain. So if not all pain is unpleasant, much of our pain response must be determined by factors other than the extent of tissue damage.
But pain affects our clinical assessment. In our search for diagnoses we may miss the point. We should address the reason people come to the ED – yes, they want to know why it hurts, but they’ve come because it hurts, so let’s help with that. All too often I find that patients have attended looking for symptomatic relief and all we’ve done is given them a non-diagnosis (“Congratulations! You haven’t broken your neck!”). Perhaps we can rethink the way we approach children in pain to give them a better ED experience.
Pain in children is complicated by negative emotions surrounding pain, injury and hospital which include anticipatory fears about infliction of additional pain, further injury, and uncertainty about what might happen during their ED visit. It can help us to look after children if we understand a little bit about their emotional development.
Toddlers transition from stranger anxiety (being afraid of unfamiliar people, usually anyone who is not a peer) to separation anxiety (fear of being separated from their parents/caregivers). Parents certainly recognise both phenomena – so when we take children from their parents in the ED and surround them with unfamiliar adults, however smiley they might be we may be effectively making their worst nightmares come true.
There was a long held perception that neonates didn’t feel pain and clinicians used to perform all sorts of procedures including intubating without drugs. We now recognise that not only do neonates experience pain but that this pain alters clinical outcomes, brain development and subsequent behaviour. Studies show that pain experienced during the neonatal period is associated with increased pain sensitivity and hyperalgesia, changes in behavioural stress responses, and ultimately increased incidence of psychosomatic pain and psychiatric disorders in later life.
However, inflicting pain to relieve pain is not something that makes sense to young children – if you want to give IV/IM meds, “a needle to make things better” is not something that most children can rationalise. So we must think flexibly and creatively about managing pain.
For injury we have a number of options. Of course we can and should give enteral paracetamol and ibuprofen (in the UK we no longer give codeine to under 12s) – these are good drugs which work well in combination with other analgesics and last longer than medications given by other routes.
We can utilise local anaesthetic – regional blocks, like femoral nerve blocks for femoral shaft fractures can work brilliantly.
We are probably still under-using the intranasal route; diamorphine use is well established in the UK and well tolerated, but fentanyl is also widely used throughout the world and research around the use of intranasal ketamine (either at subdissociative analgesia doses or for procedural sedation) means we may see this advocated as a viable option in future. A study (small admittedly) published in the American Journal of EM this week demonstrated how introduction of a protocol for intranasal fentanyl could reduce time to administration of analgesia for children in pain.
Don’t underestimate the value of splinting and immobilising bony injuries – this can be incredibly helpful. Think sensibly about this: if a child obviously has a fracture without x-ray then of course they need an x-ray – but they’re also going to need an intervention, so why not treat the patient first by plastering them prior to x-ray? There will be a small but probably insignificant reduction in the quality of your imaging but the comfort benefit for your patient is, in my mind, a bigger priority. Also consider ultrasound prior to immobilisation – this is often well tolerated, especially if you get the child to submerge the affected limb in water.
For wounds we have great success in Manchester using LAT – lidocaine, adrenaline, tetracaine – gel (TAC – tetracaine, adrenaline, cocaine – gel exists as an alternative in North America). The gel is applied directly to an open wound and left for 45mins after which time it usually provides sufficient anaesthesia for cleaning and closure. We have anecdotally adopted the Rule of Jenner which states that if child lets you apply the gel, that’s a good predictor that they will let you complete what’s required. You can also supplement it with additional infiltrated lidocaine if you need to.
Free flowing entonox (50% O2:N2O) is a great adjunct. Older children can often use N2O with a demand valve but for younger children we use a wall delivery valve which permits us to deliver nitrous oxide (with oxygen) into a non-rebreathe mask. To use this method you require scavenging in the department but it really does work a treat. Kids can’t become hypoxic with the 50/50 mixture, will often giggle or sing to you as you manage their wounds, and the fact that a MAC of 105% is required for general anaesthesia means it won’t oversedate unless you are using it in hyperbaric conditions (ED pressure is high but not hyperbaric… yet). Obviously there are contraindications to the use of N2O due to its rapid diffusion into air spaces.
Children with illnesses can have pain too and similar principles apply. Start simple and don’t be afraid to work up. Anticipate your patient’s needs (so put the ametop/EMLA on early in anticipation that things might not feel better) – don’t wait to know the child is still in pain and then make them wait longer while the topical anaesthetic works (or go at them with a needle on non-anaesthetised skin). A recently developed device, the J-Tip, might be helpful for this in future, providing needle-free administration of subcutaneous local anaesthetic through a pressurised device. Published literature on its efficacy does seem to have industry input which always makes me sceptical but it’s certainly one to watch.
Don’t be frightened of intravenous opiates and opioids – if the child needs them, they need them. Titrate slowly with small doses and you’ll be ok. Honest!
The key to effective management of pain is the use of a combination of the above. We often use one in isolation but as long as you are mindful of dosing (particularly with local anaesthetics) you can do these things in combination – for example, for the child with a femoral shaft fracture: intranasal diamorphine, oral paracetamol or ibuprofen, topical local anaesthetic followed by an ultrasound guided femoral nerve block and application of a Thomas splint – all prior to x-ray. I have had a toddler sleep through the splint application – then you know you are doing it right.
Be prepared – be thoughtful, flexible and creative with your drug-based approach.
Address Wider Factors
Pain associated with procedures presents a slightly different set of challenges.
There are two key questions we need to ask before we embark on this journey in the ED
- Is this necessary? Is there a genuine clinical benefit to performing this procedure in the Emergency Department (not just the fact that it’s fun to give ketamine)? Does this need to be done now? Are you helping the patient avoid further (often surgical) intervention?
- Is the ED the most appropriate place? The answer to this might be multifactorial and include things like staffing capability, skill mix, ED capacity, availability of equipment. In our increasingly overcrowded EDs, the answer to this question is often no.
In terms of full procedural sedation, don’t think of sedation in isolation without analgesia. Local, regional or topical anaesthesia or any of the approaches suggested above may be used in conjunction with sedation to good effect.
Realistically you are going to invest far more time in preparation for the procedure than in doing it and that balance is absolutely appropriate. For older children, calm conversations about what is necessary and why and how it is going to happen can reduce anxiety. It may be helpful to outline or write down the steps involved, to demonstrate equipment or simulate practice.
Preparation is the key to sedation success and is, I would argue, more important than the medications you choose. Use your experienced PED nurses to help – they are expert at holding and positioning children but they are also excellent advocates for our patients. We do have a tendency to develop task-blindness (we are really good at intravenous cannulation, so we can become fixated with proving ourselves and undertaking repeated attempts) and experienced nurses can help by prompting us when a procedure is failing or the child needs a break in attempts.
Don’t jump straight in. Stop, think, invest time – it will be worth it.
Of course not everything to do with pain management is about drugs. We’ve already identified that pain responses have significant psychological, behavioural, emotional and cultural components. These can be brought into play to modify and dampen pain responses as long as you recognise and think about them.
Communication is absolutely vital, not just in what you say but in your voice and your demeanour – the way you are perceived by your patient and by their parents can determine an atmosphere which can escalate or de-escalate distress.
Parents are, of course, your greatest ally. I’m sure all ED clinicians are familiar with the anxious parent of the child in pain and have seen how their anxiety escalates the child’s pain response. You need to have the parents on your team. Take them aside and give them a pep talk. They need to know exactly what will happen and what you expect of them. Sometimes they aren’t able to provide a reassuring presence to their child and that’s ok, it’s important they recognise that and ideally identify someone else who can. And if they do a good job of reassuring their child, reward them afterwards. Get their child to give them an “awesome job!” sticker. It goes down well.
Play therapists are awesome, not least for distraction during procedures – they are the masters! We don’t make enough use of them, so involve them early, especially for children for whom procedures are anticipated to be difficult (those with learning difficulties, for example). If you don’t have an ED play therapist I’d strongly recommend putting together a business case for one – when not helping with procedures they work wonders in a crowded waiting room.
We should also think about atmosphere – we can alter pain responses using music and lighting. Music has been shown to be good for reducing anxiety during procedures in this slightly sketchy RCT (but hey, it’s music – it’s cheap and there are NO side effects) and also when using ketamine, to make emergency phenomena more pleasant.
We can also utilise alternative sensations: adjuncts like the buzzy bee have seen increasing use in the last few years. Again the evidence base is poor but harms are likely to be few and some patients swear by them. We can also consider physical comfort measures, like using warmth (especially for abdominal pain).
This video shows a fantastic example of a combination of methods used to give a good experience for a child undergoing venepuncture. The healthcare professional drawing blood is calm, relaxed and confident. The parent is providing supportive distraction. The buzzy bee is providing a distracting physical sensation.
There are several Cochrane reviews for non-pharmacological methods of comfort for neonates: swaddling is an ancient practice with evidence for soothing pain and there is also evidence for both nutritive (breastfeeding/expressed breast milk) and non-nutritive sucking (using dummies or sucrose solution). Both are recommended; in combination with suckling studies suggest quicker resolution of crying and return to normal vital signs after painful stimulus with swaddling showing a lesser rebound effect after cessation.
So paediatric pain relief is more than just calpol.
- Pain is more than nociception
- Be creative, thoughtful and flexible with drug-based approach
- Address the wider factors affecting pain response
Please be kind to children. Paediatric pain matters; it’s complicated but we can help. It’s in your interest to make things run smoothly; the biggest predictor of a bad ED experience for a child is having previously had a bad ED experience. You are investing in future ED attendances, not just for this child as a child but into adulthood and for their family too – it’s worth getting this as right as we can.
Please also promote the #ItDoesntHaveToHurt campaign on social media, designed to get evidence-based treatment of paediatric pain to parents and carers, to improve the management of paediatric pain in the community.
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