pain management in children dr david tran fvhospital a&e depatment

Pain management in children

Dr David Tran

FVHospital

A&E depatment

Pain evaluation

Each child coming in A&E with pain,

needs to have an evaluation of his pain.

This evaluation is necessary to chose the

adapted painkiller and to follow the

efficiency of the treatment.

Auto-evaluation is the best if possible

Different tools help evaluation (pain scale)

Face pain scale / Visual Analog Scale / Verbal descriptor scale

0 1 - 2 3 - 4 5 - 6 7 - 8 9 - 10

Pain assessment in infants

1 - 2

3 - 4

5 - 6

7 - 10

0

Pain assessment / age

Less than 4 years > Behavioral scaleBetween 4-6 years > Face scaleMore than 6 years > VAS or numeric scale

Scale type VAS Face Behavior

Mild pain 1 - 3 2 1 - 2

Moderate pain 3 - 5 4 3 - 4

Severe pain 5 - 7 6 5 - 6

Very severe > 7 8 - 10 7 - 10

Painkiller 3/10 4/10 3/10

Different types of painkillers

Level Painkiller

1 Paracetamol

2Codeine

Non Steroid Anti-inflammatory

Tramadol

3 Morphine

How to chose painkillerLevel 1 & 2: can be administrated by the nurse

(triage nurse)Level 3: medical prescription onlyAssociation between different levels is possible

(ex: 1 + 2 or 1 + 3)

No pain Mild painModerate

painSevere pain

Very severe pain

No use Level 1 Level 1 or 2 Level 2 or 3 Level 3

Level 1 = ParacetamolDOLIPRANE / EFFERALGANDose 15mg/Kg by mouth (better than intra-rectal)

< 5 KgDoliprane 100mg

½ sachet

5 – 8 KgDoliprane 100mg

1 sachet


1 sachet


1 sachet


1 sachet

> 27 Kg Dopirane 500mg

Level 2 : CodeineCODENFAN 0.5ml/Kg/6h (soon available in FVH)EFFERALGAN Codeine (only if > 15Kg)

Weight Posologie

15-22 Kg ½ tablet / 6h

23 – 30 Kg ½ tablet / 4h

31 – 50 Kg 1cp / 4 to 6h

> 50 Kg 1 to 2 tablets/ 4h

Level 2 : Tramadol

Authorized for children of 15 years old or more

1 tablet /every 6 hoursAssociation with paracetamol possibleThere is a sirup of tramadol (Topalgic

100mg/ml for children > or = 3 years) but not available in FVH…

Level 2 : Non Steroid Anti-inflammatory = Children’s Ibrafen® sirup

If needed, repeat dose every 6 hours

Age Weight (Kg) Dose(teaspoon)

Under 2 <11 Kg 1/2

2 - 3 11 - 16 1

4 – 5 16 - 21 1.5

6 – 8 21 - 27 2

9 – 10 27 - 32 2.5

11 32 - 43 3

Level 3 : Morphine IV

Indicated if severe or very severe painUse only if medical supervision (Pain,

consciousness, respiratory rate)

Ventilation device available (balloon, high

concentration mask, Oxygen) and Naloxone available.

Contre-indication: hepatic failure, asthma in crisis, cranial trauma, hypersensitivity to morphine

Management of morphine

Use bolus of morphine (titration)

First dose : 0.1mg/Kg IVD (always < 5mg)

Reevaluation every 5 minutes (use the same scale)

Reinjection of 0.025mg/Kg every 5 to 7 minutes if EVA > 4 (objective = EVA < 4)

There is no maximum dose but medical assessment is necessary after 5 injections

Preparation of morphine

1 ampoule of morphine = 10mg

Dilute the ampoule in 9ml of serum You get 10mg / 10ml (1mg/1ml)

First dose 0.1mg/Kg

Example: child 20Kg > needs 2mg = 2ml

of the diluted preparation.

Next bolus 0.025mg/Kg > 0.5mg = 0.5ml

Safe control during morphine treatment : 3 criteria

1. Re-assessment of the pain

2. Conscious evaluation (sedation score)

3. Respiratory Rate

Score Sedation Clinical signs

0 No sedation Alert, eyes opened

1 Mild sedation Eyes open on demand

2 Important sedation Eyes open on stimulation

3 Very severe Impossible to wake up

Respiratory depression

Respiratory rate is the best criteria with consciousness

Age Respiratory Rate

< 1 year > 20/min.

1 to 5 years > 15/min.

> 5 years > 10/min.

In case of overdose signs

Sedation score < 2 and RR to law (depend of age)

Stimulate the child and ask him to breath

Oxygenation with high concentrated mask if SaO2 < 94% 6 to 8l/min

If no improvement after stimulation, use Naloxone (NARCAN®)

Use of Naloxone = NARCAN®

1 ampoule = 0.4mg = 400g = 1ml

Posologie: 1 to 2 g / Kg IVD

Dilute 1 ampoule of 1ml in 9 ml of serum

Inject 1ml by 1ml until the child recover

normal conscious & respiratory rate

Problem: the antalgic effect of morphine is

removed

Criteria of discharged after use of morphine in children

Only after 2 hours of surveillance in A&E (after the last bolus of morphine)

Child awake (sedation score = 0)

Respiratory rate normal for the age

Parents agree for assessment at home (give and explain special form for assessment after use of morphine)

pain management in children dr david tran fvhospital a&e depatment

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