Stay on Top of Kids’ Pain in the ED
By Susan London
Elsevier Global Medical News
LAS VEGAS - Minimizing pain in children undergoing common procedures in the emergency department is essential, Dr. Amy L. Baxter said at the Scientific Assembly of the American College of Emergency Physicians.
Inadequate pain management during trauma care or painful procedures not only adversely affects clinical outcomes at the time, but also has a lasting impact on a child's sensitivity and reaction to future painful events, said Dr. Baxter, of Pediatric Emergency Medicine Associates in Atlanta.
Several recently published studies "are all finding the same thing: that hyperarousal, that pain, that posttraumatic stress are all related to how much morphine you got or didn't get just in the trauma bay," said Dr. Baxter, who is also CEO of MMJ Labs, a manufacturer of devices to reduce needle pain. "This is something that we as emergency physicians have control over."
Intranasal fentanyl has expanded options for managing trauma-related pain, she said. For example, in children with fractures, intranasal fentanyl has been found to work as well as standard intravenous morphine, with a shorter time to administration (32 vs. 63 minutes) and equivalent analgesia lasting for at least 20 minutes (Acad. Emerg. Med. 2010;17:214-7; Ann. Emerg. Med. 2007;49:335-40).
"We like to give our intranasal fentanyl using the mucosal atomizer device," Dr. Baxter commented. "Or you can just drip it in with a syringe. You don't want to give more than about 1 cc per naris, so splitting up between the nares is an effective way."
Another non-IV opioid option is hydrocodone given in triage. Lortab - hydrocodone plus acetaminophen - "is what we usually use, and the reason is that Tylenol with codeine has pharmacogenomic issues," she explained, with about 15% of children unable to metabolize the codeine to its active form. But Lortab is slow to reach peak effectiveness and hence is not a good choice if a procedure is to begin shortly.
Ibuprofen has been found to be as effective as acetaminophen with codeine for managing the pain of extremity fractures in the ED (Acad. Emerg. Med. 2009;16:711-6). "Given that the onset of ibuprofen is going to be faster, that I think should be really where we are changing our triage protocols," Dr. Baxter said.
Ibuprofen is also at least as effective as acetaminophen with codeine for home management afterward and is associated with less functional impairment due to pain (Ann. Emerg. Med. 2009;54:553-60).
"I think we are on very solid ground telling families that you could give them a Tylenol with codeine or a Lortab or an oxycodone prescription, but that really their children are probably going to be better served with their fracture care by staying on top of the pain and staying ahead of it with ibuprofen, and using plain Tylenol for breakthrough," she said. "It also helps when you are worried about prescribing opioids."
Sickle Cell Pain
Emergency physicians might be skeptical about the self-reported severity of sickle cell pain, as patients' vital signs often seem incongruous with their high pain ratings, Dr. Baxter observed. But as pain persists, autonomic responses dull over time (Prog. Clin. Biol. Res. 1987;240:265-75).
In the ED, the strongest predictor of need for admission in patients with sickle cell crisis is lack of change in pain score with the first dose of IV morphine (J. Pediatr. 2008;152:281-5). Patients who do not have any change but are given additional doses and sent home have triple the odds of coming back for readmission.
"If you don't get a response with the first dose of morphine ... just go ahead and admit them because that crisis is so socked in, they are less likely to be able to be discharged," she explained.
When it comes to topical anesthetics for lumbar puncture (LP), EMLA (eutectic mixture of local anesthetics; 2.5% prilocaine and 2.5% lidocaine) has the advantage of penetrating about 5 mm into the skin, compared with only about 2 mm for LMX4 (liposomal 4% lidocaine).
To cover the topical, "we use a big old swath of Press'n Seal [plastic wrap] because it will hold EMLA or LMX on, it doesn't have latex, it's not an infectious disease concern because you are going to clean anything before you puncture the skin, and it doesn't hurt at all to tear it off," Dr. Baxter said.
In children older than 3 months, local anesthesia with buffered lidocaine, with the amount tailored to the child's size, can be very helpful, she commented. "Make sure you wait a good minute and a half for that lidocaine to actually have an effect before you start the LP."
An added benefit of use, which might help sway reluctant colleagues, is an increased chance of procedural success. For example, among infants, the likelihood that a lumbar puncture will be successful is more than doubled when local anesthetic is used (Pediatrics 2006;117:876-81).
Children who are likely to need repeated LPs over time, such as those with cancer, have higher levels of pain and fear for both lumbar punctures and bone marrow biopsies if they receive only midazolam and EMLA before an LP, compared with propofol-fentanyl sedation (Ann. Pharmacother. 2003;37:17-22).
"So if this is a new diagnosis where this is a kid who is going to be getting a whole lot of procedures, then you will do them a better service if you go ahead and knock 'em out," Dr. Baxter said.
"We usually use propofol and ketamine if we are going to have a big abscess drainage," Dr. Baxter said. "But there are a couple of things you can do even if you are not using deep sedation and - I would argue - do them even if you are using deep sedation."
Apply and cover a topical anesthetic, preferably EMLA because of its greater depth of penetration, 1 hour beforehand, she recommended. Second, after the child is sedated, inject buffered lidocaine around the abscess and not into it, to avoid potential neutralization.
"Using an adequate local makes for a safer sedation," Dr. Baxter noted, for example, by reducing pain-induced movement and agitation. The odds of adverse events during procedural sedation are nearly tripled in children who become agitated (Clin. Pediatr. 2010;49:35-42).
When it comes to removing abscess packing, she recommended first applying a mixture of LET (lidocaine, epinephrine, tetracaine) and LMX. "The LET will wick in and it will make your gauze a little bit slushier, and that whole mess will come out more easily," she explained. "And the topical anesthetic will make the skin on top a little bit less painful as you pull the dressing out."
Topical anesthetics not only reduce needle pain but also improve the success rate of IV starts, she noted.
Of the many products for delivering lidocaine topically, EMLA with occlusion for 60 minutes is the slowest. But it has a biphasic response on vasculature, causing vasoconstriction for the first 1.5 hours or so and vasodilation thereafter, causing the successful IV rate to actually fall initially, she noted. "So LMX is a much better choice when you don't have much time."
Synera (7% tetracaine, 7% lidocaine), a heated patch, works in 20 minutes, vasodilates, and produces complete analgesia for needle sticks in 68% of children. However, it gets quite hot, can cause seizures if chewed, is expensive, and does not conform well to small extremities.
J-tip, a needle-free jet-injection system, is provided as a carbon dioxide cartridge on an empty syringe that the hospital fills with anesthetic. It is more effective than EMLA at providing complete analgesia in 7- to 19-year-olds (84% vs. 61%) (Anesth. Analg. 2003;96:215-9). But it is also fairly expensive and causes a loud pop that children must be warned about.
The lidocaine bleb, injected using a 30-G needle over the vein where an IV will be started, is the fastest technique for reducing needle pain. "If you can get people used to doing two sticks, it is the best pain relief of any of these options," she commented. "There is a little learning curve to it, and if you put the bleb of lidocaine in the wrong spot, you can vasoconstrict or make it actually where the needle is not going to be going in."
In cases of especially difficult IV access, consider subcutaneous infusion facilitated by hyaluronidase (Pediatrics 2009;124:e858-67). Lactated Ringer's solution will sting less than normal saline.
For pain due to lacerations and wound closure, LET applied topically for 20 minutes beforehand provides pain relief for at least 73% of facial lacerations and 45% of extremity lacerations (Ann. Emerg. Med. 1998;32:693-7).
"The only issue is that with vermilion-border lacerations ... you can lose your landmarks," Dr. Baxter cautioned, so infiltrating with local anesthesia might be better for those wounds.
In addition to these pharmacologic approaches, physicians can use neurally mediated methods for reducing needle pain, such as application of vibration or a cold sensation, according to Dr. Baxter. And distraction has been shown to work well (Anesth. Analg. 2006;102:1372-5).
Children can often be distracted with toys or games. Or they and their parents can be given a job. "Either have the parent teach the child breathing or have them count something," she recommended.
"One counterintuitive thing is that empathy and reassurance actually increase children's distress," she noted. Therefore, don't apologize, and stop parents from asking the child if it hurts; instead, use humor and give directions regarding coping strategies.
"Advanced emergency departments that are good at pain control are moving more toward [using a] a position of comfort, not only letting the family stay in the room for the procedure, but also actively involving them, having them hold [the child] for IVs or lacerations," she observed. "Having a parent behind them holding them in a position of comfort is a great way to decrease pain and stress."
Finally, allow children to watch the procedure if they want to. Some 20% will not want to watch at all, and 20% will want to watch the whole thing. The other 60% will just check in periodically. "Most kids kind of see what you are doing and then look away," Dr. Baxter said.