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

Pain sensitization Tissue ischemia Inflammation Increased pain Alpha 2 + Inflammation = Reperfusion Reperfusion = Increased pain Hey man, this hurts!

Carroll, Mackey, Gaeta 2007 PAIN MGT PERCEPTIONS In hospital The patient vs The treatment

Prehospital The patient vs The treatment Peds vs Adults in Pain Pediatrics

Adults Simpler concerns Complex concerns Injury misconceptions

Understands injury Response mediated by environment Response is more internally mediated

Eric Fleegler, MD 2016 ASSESSMENT AND DECISION MAKING The Wong-Baker Scale

Pain Scales Pain scales look great in the chart Use the my child rule Use the Golden Rule Use your Humanity Okay, I think I understand pain

What can I do to make a difference?

Why most prehospital pain algorithms fail No established goals We fail to educate or encourage We fail to adapt We use in-hospital algorithms We dont consider pain mgt alternatives

How NOT to fail! 1. 2. 3. 4. Establish goals

Educate on pain, encourage mgt Adapt (CQI based on goals) Focus on what works in the prehospital setting Establish Goals Fix pain How often can it be managed with

more basic maneuvers? How often should complaint of pain receive medication? What is your measure of success? Establish Goals Document that we fixed pain Pain score matters in documentation,

not practice Encourage providers to document comfort response Higher comfort > lower pain score Educate on Pain Let everyone know how pain works Explain pain

Explain the role of stress & sympathetic tone Explain the role of psychological and distraction options Explain the pharmacology Educate on Pain Educate the differences between ped

pain and adult pain Peds respond to environment Peds respond to stressors Peds have misconceptions with injury Educate on Pain Pain management is safe, effective, and expected!

Adapt CQI based on goals Are we meeting goals? If not, how do we improve this? If so, and the goals are insufficient, how do we make them better?

Our System CQI and Goals 2010-2014 Primarily IV morphine based Minimal education on meds Not encouraged to use them Afraid of meds No CQI performed on effectiveness

Our System CQI and Goals 2015 LOTS of route options LOTS of education EXPECTED to MEDICATE!!!!! Alleviated fears Massive new CQI system EMS providers give input monthly

Our Goals 1. Legitimate pain reported gets mgt Good documentation 2. Proper dose administered 3. Identified response from dose Relaxation, restfulness

Those arent normal hospital goals Matt, your goals are nonspecific I am a transformational leader Most hospital goals are transactional, which is less effective at obtaining results


Peds respond to environment Make the environment suitable Parents Comfortable distance Eye level Noise / lights Peds respond to stressors

Calm and reassure Distraction Laughter BLS Maneuvers

Splinting Covering Resting Position of comfort

Keep the wound clean Ice, where acceptable LETS TALK DRUGS As tradition would have it We (EMS, RN, MD) tend to forget everything we learned in school

Drug absorption factors Bioavailability Situational effectiveness In reality everyone gets 2mg of morphine What works in the prehospital setting?

The ideal prehospital drug for ped pain Potent Wide Safety Profile Situational dosing

Short Duration of Action Minimal Side Effects Cost Effective Minimal Contraindications

Easily Deployable (Alternative Routes) NON-NARCOTICS Acetaminophen Pros

Potent Large therapeutic dose range Minimal side effects

Minimal contraindications Easily deployed Acetaminophen Cons

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

Pros Potent

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

Ketamine Pros

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!

@MedicOzMosis Email: [email protected]

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