Transcript Continuum of Acute Pain Management in Children

Pediatric Prehospital Pain
Management: the ED perspective
Emergency Medicine Symposium
October 3, 2008
Michael K. Kim, MD, FAAP
Pediatric Emergency Medicine
UWSMPH
Objectives
• Historical model
• Barriers prehspital and ED
• Evidence based advances and future
Reference case
Your 5 year old son
Johnny falls off the
backyard jungle gym
and has a deformed
arm. Patient has an IV
started and receives 2
mg of morphine in route.
Issues
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Head injury
Unable to obtain vital signs
Prolonged transport
morphine versus fentanyl
– routes of administration
• Role of accepting MD/medical control
– Level of transport service
– Factors for additional doses
Advancement in pre-hospital care
• “scoop and run”
– GTHTTH
• “stay and play”
• “play and run”
Pre-hospital
• 14.5 million EMS transports annually
– Moderate to severe pain in 20%
– 50% are children
– McLean SA, PEC, 2002
• Only 6 papers prehospital pain management
(1980-1996)
• Challenges and barriers in prehospital setting
– Consent
– Methodology
Statements
• “Relieving discomfort may be the most
important task EMS providers perform for
majority of their patients.” ACEP 1997
• “Relief of discomfort is the most relevant
outcomes measure for majority of prehospital conditions” EMSOP / NHTSA 1999
In the perfect world…
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Assess for circulation and sensation
Check for other injuries
Age appropriate pain assessment 8/10
Screams with attempts to splint
Imagery, start IV, fentanyl
5 minutes later, pain score is 3/10
Arm is splinted with minor discomfort
Gently placed in the rig and slow ride to ED
Reassessment before ED; pain score 2/10
Prehospital opioid administration
for fractures
White 1999
McEachin 2002
Hennes 2003
Adults
Adults
Adults
Swor 2005
children
Adults
children
Prehospital
1.8%
18.3%
10.5%
3.0%
26.3%
21.2%
ED
91.1%
87.8%
91.1%
Time to first dose of opioid
Swor 2005
Silka 2002
Hennes 2006 (unpublished data)
Pre-hospital
22 min
ED
88 min
17 min
109 min
57 min
Scoop and run result in significant delay in
analgesic administration.
Pain Management Barriers
• Provider barriers
• System barriers
• Patient barriers
Survey data
Hennes, et al. Prehospital Emerg Care 2005;9:32-39
• Reasons for withholding morphine in
children
– Inability to assess pain
– Patient refusal
– Drug seeking behavior
– No indications for vascular access
Common assumptions & attitudes
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There is given amount of pain for given injury
Newborn babies do not feel pain
Children have no memory of pain
Children metabolize opioid differently
Children may become addicted to narcotics
Pain is character building
Use of pain medication is sign of weakness
No pain, no gain
Provider barriers
Kim et al. 2006 NAEMSP abstract
• Doubts the need for pain management
• Lack of education
– Pain physiology & pharmacology
• Difficulty in pain assessment
– Lack of easy to use assessment tool for children
– Questions the validity and reliability of tools
• Negative incentives
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Need for an IV & difficult IV
Transport time
Work load
Negative feedback from Docs
System barriers
• Lack of education
– Physiology, assessment, pharmacokinetics,
outcomes data
• Medical control
– Reluctant to provide pain meds
– Ricard-Hibbon 1999 & Fullerton-Gleason 2002
• Multiple tiered system
– EMT vs. paramedic
Patient barriers
• No pain meds prior to ED (74%) Spedding 1999
– harmful
– hospital’s responsibility
– not available
• 70% of adults with severe pain did not ask
for pain medication Richrd-Hibbon 1999
ED physicians
When should EMS provide analgesia?
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based on the obvious deformity it’s so
easy….just get a doctor and get the morphine
Transport time again
What if I have a little finger….put an IV in
depends too on how bad it actually looks
I think if it is obviously deformed they think
they should put an IV in
Don’t they have to call the doctor if they have
an IV?
ED physicians
Is prehospital pain management a benefit?
• Yes
– Calmer patients
– Expedites evaluation
– If it is grossly deformed, no problem
• No
– If short transport time
– Unable to evaluate
– If they mess up…
ED physicians
Focus group summary 2004
• Not aware of pain protocols
• Limited experience with prehospital pain
management
• Pain assessment report is rarely given
• It seems easy to OD kids
Evidenced interventions
• Protocol liberalization Pointer et al. PEC 2005
– Online to offline administration of morphine
– 2.8% to 19% increase in MS administration
• Education French et al. PEC 2005
– 3 hour educational intervention
– Pain med use
20.4% to 24.5%
– NP intervention 2.5% to 34.7%
– Pain scores
44.5% to 95.4%
Milwaukee Prehospital Pain
Management Group
• ‘Impact of an educational module on prehospital
pain management in children’
• Targeted Issue Grant by EMSC 2004-2007
• PAMPPER (Pain Assessment and Management
for Prehospital Pediatric EmeRgencies)
Reference Case
Consider following issues during the presentation
Q1: Why is prehospital pain management important?
Q2: Initial assessment and intervention?
Q3: Best method of pain assessment?
Q4: Indications for pain management?
Q5: What determines the need for pain medications?
Q6: What medications should be considered?
Q7: Dose and route of administration?
Negative Effects of Untreated Pain
• Interferes with normal bodily function
– Increased metabolic rate
– Interferes with clotting
– Alters immune function
• Emotional stress/Suffering
– Anxiety (Fear of unknown)
– Powerlessness
– Loss of control
Q1: Why is prehospital pain management important?
Pain results in a stress response
• Biochemical: stress hormone release
– Epinephrine and norepinephrine
– Steroids, growth hormone, and glucagon
– Increase metabolic rate
• May cause cardiopulmonary instability
• Physiologic
– Tachycardia, tachypnea, BP elevation
• Behavioral
– Facial grimace
– Physical withdraw, kicking
– Crying
• The response varies in every patient based on age,
development, and prior experience
Pain results in a stress response
• Biochemical: stress hormone release
– Epinephrine and norepinephrine
– Steroids, growth hormone, and glucagon
– Increase metabolic rate
• May cause cardiopulmonary instability
• Physiologic
– Tachycardia, tachypnea, BP elevation
• Behavioral
– Facial grimace
– Physical withdraw, kicking
– Crying
• The response varies in every patient based on age,
development, and prior experience
Pain results in a stress response
• Biochemical: stress hormone release
– Epinephrine and norepinephrine
– Steroids, growth hormone, and glucagon
– Increase metabolic rate
• May cause cardiopulmonary instability
• Physiologic
– Tachycardia, tachypnea, BP elevation
• Behavioral
– Facial grimace
– Physical withdraw, kicking
– Crying
• The response varies in every patient based on age,
development, and prior experience
Pain results in a stress response
• Biochemical: stress hormone release
– Epinephrine and norepinephrine
– Steroids, growth hormone, and glucagon
– Increase metabolic rate
• May cause cardiopulmonary instability
• Physiologic
– Tachycardia, tachypnea, BP elevation
• Behavioral
– Facial grimace
– Physical withdraw, kicking
– Crying
• The response varies in every patient based on age,
development, and prior experience
The evidence:
Opioids decreases the stress response
• Pain and its effects in the human neonate and fetus.
Anand KJ. NEJM. 1987;317(21):1321-9.
– A landmark publication that called into question the widely
held belief that neonates do not have the neurophysiologic
apparatus to experience pain
– Also decreased stress response and decrease morbidity and
mortality after major surgery in neonates.
• Neonatal and pediatric stress responses to
anesthesia and operation. Anand KJ. Int Anes Clin. 1988
;26(3):218-25.
– Benefit seen beyond neonatal period
The evidence:
Effect of single painful procedure
• Effect of neonatal circumcision on pain response
during subsequent routine vaccination.
– Taddio et al. Lancet. 1997:349(9052);599-603.
– No pain management during circumcision results in
increased pain response at 4-6 months later
• Consequences of inadequate analgesia during
painful procedures in children. Weisman et al. Arch Ped
Adolesc Med 1998
– Inadequate pain management during spinal tap results in
increased pain scores during subsequent procedures
Q1: Why is prehospital pain management important?
Why is prehospital pain
management important?
• Decreases pain and suffering
• Provides comfort during transport
• Expedites evaluation and interventions
in the emergency Department
• May improve outcome
Most appropriate pain scale
for 4 to 16 years
• Faces Pain Scale -Revised
–The Faces Pain Scale - Revised: Hicks CL et al.Pain 2001;93:173-183.
–Validated in children“true representation of pain”
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“These faces show how much something can hurt. This face (point to the leftmost face) shows no pain. The faces show more and more pain (point left to right)
up to this one (point to right –most face) it shows very much pain. Point to the
face that show how much you hurt now.”
Q3: Best method of pain assessment?
Pre-hospital Pain Interventions
• ABCDEs first
• Nonpharmacologic
• Pharmacologic
Q4: Interventions for pain?
Non-Pharmacologic Pain Interventions
Injury specific
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Rest
Ice
Compression
Elevate
Splinting
Dressing
Positioning
Q4: Interventions for pain?
Non Pharmacologic Pain Interventions
Fear and Anxiety reduction
Method
Age
Description (examples)
Talking
All
Form of distraction (explanation)
Distraction
All
Toys, books, music, talking…
Parental presence
All
Reassurance and familiarity
Patient Control
>3y
Retains self control
Imagery
>3y
Imagining being elsewhere
Truth
>5y
Be honest (this needle will hurt a bit)
Explanation
>5y
Removes the fear of unknown & announces
what to expect
Q4: Interventions for pain?
When non-pharmacologic
interventions are not enough?
• Reassessment of pain
• Pharmacologic intervention
– Continued moderate to severe pain (score  4)
– morphine sulfate
Q4: Intervention for pain?
Q5: What determines the need for pain meds?
Q6: What meds should be considered?
Pharmacologic interventions
• Morphine
– Gold standard
– IM/IV/SQ
• Fentanyl
– Less hemodynamic effects
– IM/IV/IN
Wisconsin pain management guideline
(EMSC recommendations)
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Assessment: 0-10 faces scale
Interventions: non-pharmacological
If pain score > 4, morphine 0.1 mg/kg
May repeat every 10-15 min up to 10 mg
Only if SBP > 80 in children
Fentanyl per local EMS guideline
Medical control for additional doses
Reference case
Your 5 year old son
Johnny falls off the
backyard jungle gym
and has a deformed
arm. Patient has an IV
started and receives 2
mg of morphine in route.
Issues
•
•
•
•
Head injury
Unable to obtain vital signs
Prolonged transport
morphine versus fentanyl
– routes of administration
• Role of accepting MD/medical control
– Level of transport service
– Factors for additional doses
Emergency Department events:
Patient with a fracture
• Without prehospital
pain management
• With prehospital
pain management
– Initial evaluation by
– Initial evaluation by
nurse and physician
nurse and physician
– IV start
– Radiograph
– Pain meds
These 2 steps can be
eliminated if patient’s
Manipulation of
– Radiograph
pain is adequately
controlled
extremity for x-ray
is Painful
* ED staff may not be able to evaluate patient immediately!!!
Q1: Why is prehospital pain management important?
Why is prehospital pain
management important?
Implications for the ED
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Awareness of the EMS protocols
Confidence in EMS providers
Voice in your EMS system
Patient advocacy
Continuum of pain management
Overview
• Prehospital pain management is important and
needs improvement.
• EMS providers need expertise of ED providers
• ED providers must know the EMD protocols
• Pain management is a continuum
“To cure sometimes, to relieve
often, to comfort always”
15th century French description of role of physician