Successful Pediatric Pain Management Matt Ozanich, MHHS, NRP Director of Pre-Hospital Care Trumbull Memorial Hospital Disclaimer Always follow local protocols
Always follow administrative policy Always do what is in the best interest of the patient Objectives Review the science/theory of pain Review pediatric pain vs adult pain Discuss how to set pain mgt goals
Discuss real-world examples of good/bad management of ped pain Discuss evidence-based suggestions for 2016 on ped pain mgt
About Us Trumbull Memorial Hospital Medical Command January 14, 2015 new EMS protocol Written primarily by EMS providers Emphasis on pre-hospital studies, not in-hospital studies
Dr. Tim Noonan, MD PHTLS 8th ed. panel discussion Someone else routinely using medical treatments without evidence is not a good reason to do the same. Charles Kettering
American Engineer, General Motors If youve always done it that way, its probably wrong. High achievement always takes place in the framework of high expectation. Paramedic Care, 4th Ed.
EMS has, historically, done a poor job of treating pain in the prehospital setting. What is Pain? Physical discomfort caused by tissue abnormalities
What is Pain? How do we control this? Awww not this again Heres what we know for sure [Blank Page]
Pain Theory Physical Abnormalities (Extrinsic) Psychological Duress (Intrinsic) Systemic Changes (Intrinsic) Pain Theory Acute Pain
Extrinsic Intrinsic Chronic Pain Extrinsic
Intrinsic Specificity Theory Receptor (brain) Pathway (spinal tract)
Origin (nociceptor) Moayedi & Davis 2013 Pain Theory Gate Control Theory Nociceptor (pain receptor) Pathway
Moayedi & Davis 2013 Pain Theory Gate Control Theory Somatosensory Pathway (normal sensation) inhibits Nociceptor Pain Theory
Central Sensitization Theory Latremoliere & Woolf 2009 Pain Theory Adrenergic sensitivity theory Injury Nociceptor stimulated
Pain Catecholamines release Vasoconstriction Reduced pain Catecholamines again By unknown mechanisms
Long onset and duration via PO If PO - cant give if nauseated IV APAP is very expensive Supp route is a well supp route Ibuprofen
Familiar Minimal side effects Minimal contraindications Easily deployed though limited route options Ibuprofen Cons
Long onset and duration via PO If PO - cant give if nauseated Narrow therapeutic dose range Ketorolac Pros
Familiar Potent Minimal side effects Minimal contraindications
Ketorolac Cons Long duration of action Narrow therapeutic dose range Not easily deployed NARCOTIC OPTIONS
Morphine Pros Potent Familiar Morphine Cons
Narrow safety profile LONG duration Side Effects galore
Contraindications galore Horrible success via alternative routes Fentanyl Pros
Potent Large therapeutic dose range Short Duration of Action Minimal side effects
Minimal contraindications Easily deployed Fentanyl Cons Still may cause hemodynamic instability Still may affect respiratory drive Situational effectiveness
Potent Large therapeutic dose range Short Duration of Action Minimal side effects Minimal contraindications Easily deployed
Ketamine Cons Side effects are very visual and unfamiliar Ketamine is unfamiliar outside of anesthesiology Situational effectiveness
Food for Thought Alternative routes need routespecific doses 10mg ketamine IM = 6mg ketamine IV 10mg ketamine neb = 6-8mg ketamine IV 10mg ketamine IN = 2mg ketamine IV 100mcg fentanyl IN = 80mcg fentanyl IV
Food for Thought Sometimes you just need more meds. If you had full thickness burns over most of your body, what would be your expectation of pain relief? Consider a Painful Procedures
protocol for these instances Food for Thought The things we say: Were pretty close to the hospital Avg time from injury to analgesia By EMS 23 minutes
By ED 113 minutes Abbuhl, F; Reed, D.: 2003 PEC7 Food for Thought The things we say: Pain mgt delays transport No significant delay
Emphasis on alt routes Turturro, M: 2002 PEC6 Food for Thought The things we say: Pain mgt can have dangerous adverse events
2100 + patients received analgesia in ambulance 12 patients had adverse events 1 required intervention Kanowitz, Dunn, Kanowitz, Dunn, Vanbuskirk: 2006 PEC10
Food for Thought The things we say: Medicating abd pain and head injuries makes assessment at the hospital difficult Opioids increase accuracy of abd exam
Allowing pt to stay stressed and in pain increases ICP Tentillier, E; Ammirati, C: 2000 Ann Fr Anesth Reanim19 Works Cited 1. Acidremap, Inc. (2015, September 18). EMS Protocols. Retrieved August 1, 2015, from Paramedic Protocol Provider: http://www.emsprotocols.org/
2. Abbuhl, F., & Reed, D. (2003, October). Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance. Prehospital Emergency Care, 7(4), 445-7. 3. Ahuja, V., Mitra, S., & Rashi, S. (2015). Nebulized ketamine decreases incidence and severity of post-operative sore throat. Indian Journal of Anaesthesia, 37-42. 4. American Academy of Emergency Medicine. (2015). AAEM History. Retrieved August 1, 2015, from American Academy of Emergency Medicine: http://www.aaem.org/about-aaem/aaem-history 5. American Academy of Pediatrics. (2014). Pediatric Education for Prehospital Professionals. Burlington: Jones and Bartlett Learning.
6. American College of Emergency Physicians. (2014). Facts About ACEP and Emergency Medicine. Retrieved August 1, 2015, from American College of Emergency Physicians: http://www.acep.org/Content.aspx?id=25240 7. Borland, M., Jacobs, I. G., King, B., & O'Brien, D. (2007). A Randomized Controlled Trial Comparing Intranasal Fentanyl to Intravenous Morphine for Managing Acute Pain in Children in the Emergency Department. Annals of Emergency Medicine, 335-340. 8. Buck, M. L., Hofer, K. N., & McCarthy, M. W. (2008). Use of Hydromorphone in Children and Adolescents. Pediatric Pharmacotherapy, 14. 9. Chang, S., Moore, L., & Chien, Y. (1988). Pharmacokinetics and bioavailability of hydromorphone: effect of various routes of
administration. Pharmaceutical research, 718-21. 10. Charlton, J. E. (2005). Core Curriculum for Professional Education in Pain. International Association for the Study of Pain Press, 1-12. 11. Coda, B., Rudy, A., Archer, S., & Wermeling, D. (2003). Pharmacokinetics and bioavailability of single-dose intranasal hydromorphone hydrochloride in healthy volunteers. Anesthesia and Analgesia, 117-123. 12. Cole, J., Shepherd, M., & Young, P. (2009). Intranasal fentanyl in 1-3-year-olds: a prospective study of the effectiveness of intranasal fentanyl as acute analgesia. Emergency Medicine Australasia, 395-400. 13. Committee on Psychosocial Aspects of Child and Family Health. (2001). The Assessment and Management of Acute Pain in
Infants, Children, and Adolescents. American Academy of Pediatrics, 793-800. 14. Davis, G. A., Rudy, A. C., Archer, S. M., Wermeling, D. P., & McNamara, P. J. (2004). Bioavailability and Pharmacokinetics of Intranasal Hydromorphone in Patients Experiencing Vasomotor Rhinitis . Clinical Drug Investigation, 24. 15. Kanowitz, A., Dunn, T., Kanowitz, E., Dunn, W., & Vanbuskirk, K. (2006, January). Safety and effectiveness of fentanyl administration for prehospital pain management. Prehospital Emergency Care, 10(1), 1-7. Works Cited
16. Levitan, R. M. (2014, July 23). Airway Course in a Box. Hanover, New Hampshire, United States of America. 17. Ma, C. B. (2013, October 14). Pain and your emotions. Retrieved August 21, 2015, from U.S. National Library of Medicine: https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000417.htm 18. Madati, P. (2011). Ketamine: Procedural Pediatric Sedation In The Emergency Department. Pediatric Emergency Medicine Practice, 1-20. 19. Mayo Clinic Staff. (2013, July 19). Stress symptoms: Effects on your body and behavior. Retrieved August 21, 2015, from Mayoclinic.org: http://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-symptoms/art-20050987 20. National Highway and Traffic Safety Administration. (2015). Morphine. Retrieved August 23, 2015, from National Highway and
Traffic Safety Administration: http://www.nhtsa.gov/people/injury/research/job185drugs/morphine.htm 21. NCLEX-RN Review. (2006, February 17). NCLEX-RN Review. Retrieved April 17, 2016, from Prentice Hall: http://www.prenhall.com/divisions/ect/app/londonbridge/pages/london_final_ch42.pdf 22. Noonan, T. (2013, January 17). PHTLS 8th Edition List Archives. Retrieved September 20, 2015, from Trauma.org: http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2013-January/053020.html 23. Penson, R. T., Joel, S. P., Roberts, M., Gloyne, A., Beckwith, S., & Slevin, M. (2002). The bioavailability and pharmacokinetics of subcutaneous, nebulized and oral morphine-6-glucuronide. British Journal of Clinical Pharmacology, 347-354. 24. Physician's Desk Reference. (2015, December 15). Drug Summary. Montvale, New Jersey, United States.
25. Ricard-Hibon, A., Chollet, C., Belpomme, V., Duchateau, F., & Marty, J. (2003, October). Epidemiology of adverse effects of prehospital sedation analgesia. American Journal of Emergency Medicine, 21(6), 461-6. 26. Schlereth, T., & Birklein, F. (2008). The sympathetic nervous system and pain. Neuromolecular medicine, 141-147. 27. Stanski, D., Greenblatt, D., & Lowenstein, E. (1978). Kinetics of intravenous and intramuscular morphine. Clinical Pharmacology and Therapeutics, 52-59. 28. Tentillier, E., & Ammirati, C. (2000). Prehospital management of patients with severe head injuries. Annals of French Anethesia and Reanimation, 19, 275-81. 29. Tovian, S., Thorn, B., Coons, H., Labott, S., Burg, M., Surwit, R., et al. (2015). Stress effects on the body. Retrieved August 21,
2015, from American Psychological Association: http://www.apa.org/helpcenter/stress-body.aspx 30. Turturro, M. (2002). Pain, priorities, and prehospital care. Prehospital Emergency Care, 6, 486-488. 31. Younge, P., Nicol, M., & Kendall, J. (1999). A prospective randomised pilot comparison of intranasal fentanyl and intramuscular morphine for analgesia in children presenting to the emergency department with clinical fractures. Emergency Medicine, 90-94. 32. Zanaty, O., & El Metainy, S. (2015). A comparative evaluation of nebulized dexmedetomidine, nebulized ketamine, and their combination as premedication for outpatient pediatric dental surgery. Anesthesia and Analgesia, 167-171. Follow Me!
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