Transcript Morphine

The Ouchless Emergency
Department
Bruce Minnes MD, FRCPC
Staff Physician and Assistant Professor,
Division of Paediatric Emergency Medicine
Chief Medical Editor, AboutKidsHealth
SickKids and The University of Toronto
[email protected]
Disclosure and Acknowledgement
I have no conflict of interest to declare.
I don’t like pain.
Thanks to Dr. Suzan Schneeweiss and to the
2011 IPEME students from Canada and various
parts of the Middle East
Learning Objectives
At the end of this session you will be able to:
• Recognize the need for appropriate pain
management in the emergency department
• Identify techniques for pain assessment
• Incorporate pain management strategies in
the emergency department
Background - General
• “The relief of pain should be a human right”1
• Children do not feel pain the same way adults…a
myth?3
• Pain causes negative emotions such as fear, anxiety,
sadness, and separation2
• Children’s pain is often underestimated…why?3
1: Taylor, EM et al. (2008), 2: Yoo, H et al. (2011), 3: Zempsky et al. (2006)
Background - Epidemiology
• Pain is major and common complaint in hospitals
(>75%)1
Iatrogenic oligoanalgesia:
• >50% of hospitalized children receive inadequate
pain management2
• Only 1 out of 4 children had pain management
during painful procedures3
1: Taylor EM, et al. (2008), 2: Stinson J, et al. (2008), 3: Stevens, BJ. et al. (2011)
Pain: 5 Myths
1. “If it doesn’t kill you it makes you stronger”
or, “No pain, no gain”.
2. It’s all in their heads.
3. Children don’t feel pain in the same way or at
all (or forget about it quickly).
4. The only way to manage pain is with strong
medications
5. Narcotics pose a high risk of dependency or
adverse effects in children.
Background - Defining Pain
•
Unpleasant sensory and emotional experience
associated with actual or potential tissue damage1
•
Physiological, behavioral, emotional, developmental, and
sociocultural components1
•
Needle puncture is among the most feared experiences
(posttraumatic stress disorder can occur!)
•
For our purposes: distress + anxiety included within pain
1: Uman LS, et al. (2006), 2: Zempsky et al. (2004)
Pain, Anxiety or Both?
Why Treat Pain?
• Alleviate suffering
• Reduction in child and
parent anxiety
• Increased compliance
and cooperation of
child
• Reduction in long
term negative effects
of pain
Recognition and Treatment of Pain
• Better understanding of pain
• Changes in attitude
• Introduction of ‘pain services’ in
hospitals
• Under treatment of pain in children
remains an issue
‘Oligoanalgesia’
• Children receive less analgesia than adult
counterparts
• Younger children generally receive less
analgesia than older children
• Children receive less medication than
prescribed regardless of reported pain level
• Many children endure unacceptable levels of
pain during hospitalization
Pain in the Emergency Department
Self Report of Pain Survey
• 533 school age children
• 50 % pain due to MSK injury
• Mean pain intensity 5.2
– At discharge 4.1
• 22 % reported worsening pain, 26 % pain
remained same
• 23 % reported pain intensity ≥ 8/10
Johnston CC. Pediatr Emerg Care May 2005.
Pain in the Emergency Department
• Only 39% received
analgesics during
the visit
• 11% were given a
prescription for
analgesics at
discharge
Johnston CC. Pediatr Emerg Care May 2005.
Analgesics by Age
Very Young (%) School Age (%)
6 mo – 24 mo
6 – 10 yrs
All Fractures
29.4
51.3
Displaced
fractures
All Burns
45
78.1
50
75
Second degree 57.1
burns
66.7
Alexander J, Manno M. Ann Emerg Med 2003
Parental Administration of Analgesics
for Limb Injuries
• 72 % of parents tried to relieve pain
– 44% non-pharmacologic methods e.g. ice
– 28 % used analgesics
• Average pain score 6.7 +/- 2.7
• Concern analgesics would mask signs and
symptoms, believed child not in pain, did
not want to delay treatment
Maimon et al. Pediatr Emerg Care 2007
Long Term Effects of Pain
• Conditioned anxiety responses
• Increased response to pain
• Diminished analgesic response at subsequent
visits
• “Blood-injection-injury phobia”
– Affects 10 % of adult population
Effects of Pain
• Circumcision male infants
– No analgesia vs. analgesia
– Increased response to immunizations at 4 to 6 months
Taddio et al. Lancet 1997; 599-603.
• Children undergoing bone marrow or LP
– Placebo vs. analgesia initially
– Subsequent procedures all received analgesics
– If received placebo initially, consistently rated pain of
subsequent procedures higher
Weisman SJ et al. Arch Pediatr Adol Med 1998;147-149.
What are the barriers in the emergency
setting?
• Children present with a constellation
of symptoms and no final diagnosis
• Delay in treatment
• Heightened parental and patient
anxiety level
• Busy, fast-paced environment
Approaches to Pain Assessment
• Pain assessment – 5th Vital Sign
• Physiological measures
– Non-specific
– ↑ HR, RR, BP, autonomic responses
• Behavioural observation
• Self report
– Choose developmentally appropriate tools
Pain Assessment
• Self report considered “gold standard”
18 – 24 months Pain words
e.g. “ow,” “hurt,” “ouch”
3 – 4 years
Degree of pain can be
reported
> 6 years
Detailed description of
pain quality, intensity,
location
Pain Scores
• Use of pain score in triage improves use of analgesia
(25 % → 36 %)
Nelson et al. Am J Emerg Med 2004
• Documentation of pain scores improves analgesic
administration in the ED
(33 vs 60 %)
Silka et al. Acad Emerg Med 2004.
• Triage pain assessment improves times to analgesia
(2.3 →1.6 hrs)
Boyd RJ and Stuart P, Emerg Med J 2005.
Question
A 4 yr old presents with pain and swelling of the
left forearm after having tripped over a toy car.
How would you assess this child’s pain?
1. FLACC scale
2. FACES scale
3. Numerical scale
4. Word scale
5. Pain scores are not reliable in younger children
FLACC
Categories
0
1
2
FACE
No particular
expression or
smile
Occasional grimace or frown,
withdrawn, disinterested
Frequent to constant quivering
chin, clenched jaw
LEGS
Normal position or
relaxed
Uneasy, restless, tense
Kicking or legs drawn up
Activity
Lying quietly, normal
position, moves
easily
Squirming, shifting back and forth,
tense
Arched, rigid or jerking
Cry
No cry (awake or
asleep)
Moans or whimpers, occasional
complaint
Crying steadily, screams or sobs,
frequent complaints
Consolability
Content, relaxed
Reassured by occasional touching,
hugging or being talked to,
distracted
Difficult to console or comfort
TOTAL SCORE between 0-10
Merkel, SL et al. Pediatric Nursing 1997;23: 293-297.
Faces Pain Scale – Revised
(FPS-R)
• Score the chosen face 0,2,4,6,8 or 10, counting left to right, so
‘0’ = no pain and ’10’ = very much pain
• www.painsourcebook.ca IASP©
Hicks et al. Pain 2001.
Word Scale
• Ask the child to classify the pain into one of 4
categories
“none”
“a little”
“medium”
“a lot”
Numerical Rating Scale
0-10
• >7 years for procedural, acute and chronic
pain
• Able to count up to 10, understand
classification and seriation
• language comprehension
• “If 0 is no pain/hurt and 10 is the worst pain
imaginable, how much pain are you having
right now?”
Management Strategies
• Non-pharmacologic
• Pharmacologic
– Analgesics
– Sedative
Non-Pharmacologic Strategies
Environment
Distraction Techniques
Child Life Specialist
Parental Presence
during procedure
Question
An 18 month old boy sustained
second degree burn on his chest
after spilling hot tea from a cup.
He is crying inconsolably.
How would you manage this
child’s pain?
A. Acetaminophen PO/PR
B. Fentanyl IN
C. Acetaminophen + Codeine PO
D. Morphine IV
E. Acetaminophen PO + IV
morphine
Ladder Effect
Pain Severity
Agent of Choice
Mild Pain
Acetaminophen +/- NSAID
Moderate Pain Acetaminophen +/- NSAID + low
dose morphine
Severe Pain
Acetaminophen +/- NSAID
morphine or other strong opioid
NSAIDS and Acetaminophen
• NSAIDS
– Little advantage of injected vs. oral
– Good post-operative analgesia
• Except tonsillectomy -> bleeding
• Acetaminophen
– Oral vs. rectal
– Rectal
• delayed and variable uptake, prolonged clearance
• Single dose 30 – 40 mg/kg , neonates 20 mg/kg
– Do not exceed daily cumulative dose
Oral Morphine vs Codeine
– Only 10 % of codeine converted to morphine
– “Non-metabolizers” and “extensive
metabolizers”
– Less GI side effects, more palatable
• Dose
– Codeine
– Oral Morphine
1 mg/kg q 4 h
0.3 mg/kg q 4 h
> 50 kg 10 – 20 mg q 4 h
Intravenous Opioids
• Most flexible and widely used for moderate
to severe pain
• No ceiling effect
• Morphine still the gold standard
• Fentanyl ideal for procedures
• Meperidine generally avoid due to side
effects
Relative Potencies of Intravenous Opioids
Drug
IV Dose
(mg/kg)
Frequency
(hours)
Ratio of
Equivalence
to morphine
Morphine
0.1
2–4
1
Fentanyl
0.001
1–2
80 – 100
Hydromorphone
0.015-0.02
2-4
5-7
Intranasal Fentanyl
• Painless administration of
analgesia
• Equivalent to IV morphine
for pain
• Onset 5 min
• Dose 1.4 mcg/kg
• No serious adverse effects
Borland, M. et al. Ann Emerg Med 2007
Question
Children are more
sensitive to the potential
side effects of narcotic
medications?
A.True
B.False
Narcotics and Pain in Children
• Pain underestimated because of fear of oversedation, respiratory depression, addiction
and unfamiliarity with use of sedative and
analgesic agents
• Tend to withhold opiates or prescribe
inadequate dose
• Sickle cell and addiction < 1% (0.2 – 2 %)
Opioids
• Half-life of morphine
– Preterm 9 h, neonates 6.5 h
– Older infants and children 2 h
• No difference in analgesic or ventilatory
depressant effects in infants > 3 – 6 mo
• Immature respiratory-reflex responses to airway
obstruction, hypercapnia and hypoxemia at birth
• Continuous monitoring!
Question
Which of the following are effective pain
management strategies in neonates?
1.
2.
3.
4.
5.
Pacifiers
Skin-to-skin contact with mother
Sucrose solution
EMLA
All of the above
Developmental Issues
• Nociception in the newborn
– Ascending pathways fully developed
– Descending inhibitory pathways not established
• Effects of repeated painful stimuli
– “Windup” of nociceptive neurons in dorsal horn
– Hyperalgesia – increase sensitivity to subsequent
painful stimuli
Neonatal Pain Management
• Topical anesthetics are SAFE!
• Sucrose (12 – 25 %) / Glucose (30 %)
– Oral glucose more effective than EMLA for heel
sticks
Roberts et al. Peds 2002;1053-7.
• Pacifier, skin to skin contact
with mother, breastfeeding
• What is the upper limit of age?
Sucrose Solution
• Safe, easy-to-administer,
inexpensive
• 1 – 2 mL 2 min prior to
procedure on pacifier or
dripped onto tongue
• Tolerance does not
develop
• ? Ad lib to 4 times/day
Question
In the emergency setting, narcotic
analgesics may mask symptoms
or cloud mental status and should be
avoided until there is a clear diagnosis.
1.True
2.False
Analgesia and Acute Abdominal Pain
Barriers
• Subjective perception of pain by physicians
• Concern for surgical misdiagnosis
• “Disapproval of surgeon” - withholding
analgesia before surgical evaluation
• Delay in diagnosis
Kim MK et al. Peds 2003;112:1122-26.
Analgesia and Acute Abdominal Pain
RCT: 60 children 5 – 18 yrs. with abdominal
pain requiring surgical evaluation
• Morphine provided significant pain reduction
• No adverse effect on patient examination
• No effect on the ability to identify children
with surgical conditions
Kim MK et al. Acad Emerg Med 2002;281-287.
Analgesia and Acute Abdominal Pain
•
•
•
•
438 children evaluated
84 % no appendicitis; 16 % appendicitis
26 % of children received analgesics
Analgesia given more often if high probability of
appendicitis – 60 %
– Most received acetaminophen, few received
morphine
• 14 % of children were underdosed (24 % with
morphine)
Goldman RD, et al. Pediatr Emerg Care 2006;22:1:18-21.
Early Analgesia in Acute Abdominal Pain
• Randomized double-blind placebo controlled trial
108 children 5 – 16 yrs
• Morphine vs placebo
• No difference in:
– diagnosis of appendicitis
– perforated appendicitis
– children who were initially observed → laparotomy
• Mean reduction in pain score 2.2 vs 1.2 in the
placebo group
Green RS et al. Ann Emerg Med 2003;42:4:S87.
Analgesics and Evaluation
• Can use morphine for pain without affecting
diagnostic accuracy
• Use of pain medication allows child to be
more comfortable and therefore more
cooperative during a diagnostic examination
.
Question
Which of the following statements regarding the use
of topical anesthetics is true?
A.
B.
C.
D.
Maxilene and EMLA are equally effective
Application requires a doctors order
Should only be applied by nurses
May increase difficulty of IV
insertion
Topical Anesthetics
• Application at triage
– 70 % accuracy in predicting need for IV
Fein A et al. Peds 1999;104:2:e19.
• Although wait time not reduced, parental
perception of care starting at arrival
associated with improved patient
satisfaction
• Improved perception of staff’s caring and
attitude toward patients
Thompson DA et al. Ann Emerg Med 1996;28:657-665.
Topical Anesthetics
EMLA®
AMETOP ® MAXILENE ®
Lidocaine &
prilocaine
4%
tetracaine
4 % liposomal
lidocaine
Onset of
Action (min)
60
30 - 45
20 - 30
Duration of
Action (hrs)
1–2
Up to 4-6
1–2
Adverse
effects
Blanching,
erythema,
Erythema,
pruritis
Irritation,
itching
Liposomal Lidocaine
• 151 patients ages 1 mo – 17 yrs
• Lower pain scores vs. placebo
• Minimal vasoactive properties
IV first
attempt
Duration of
procedure
Lidocaine
75 %
Placebo
55%
6.5 min
8.5 min
Taddio A et al. CMAJ 2005:1691-95.
LET for Laceration Repair
(Lidocaine 4 %, Epinephrine 0.1 %,
Tetracaine 0.5 %)
•
•
•
•
Application time 20 - 30 minutes
75 – 80 % complete anesthesia
Not for mucous membranes, end organs
Soak cottonball and apply to wound with
pressure
• Dose: 3 ml (no repeats)
1 % Lidocaine
• Dosage 5 mg/kg
7 mg/kg with epinephrine
• Strategies to reduce pain with injection
– Small, long needle (30 G)
– Inject slowly
– Buffered solution: add 1ml NaHCO3 to 9 ml
lidocaine solution
• Stable at room temperature for 1 week
– Warm solution (40 – 42 °C)
www.aboutkidshealth.ca
Pain Resource Centre
Health information in Arabic from
AboutKidsHealth
‫ رعاية طفلك‬:‫األلم في المنزل‬
Summary
• Pain assessment imperative in all patients –
5th vital sign
• Anticipate painful procedures/conditions and
identify strategies to manage pain
• Distraction and comfort
• Physical strategies: sling, splint, cool pack,
etc…
• Administer analgesics!
• www.aboutkidshealth.ca