Pain management in children Dr David Tran FVHospital A&E depatment

Pain evaluation Each child coming in A&E with pain, needs to have an evaluation of his pain. This evaluation is necessary to chose the adapted painkiller and to follow the efficiency of the treatment. Auto-evaluation is the best if possible Different tools help evaluation (pain scale)

Face pain scale / Visual Analog Scale / Verbal descriptor scale 1 - 2 3 - 4 5 - 6 7 - 8 9 - 10

Pain assessment in infants 1 - 2 3 - 4 5 - 6 7 - 10

Pain assessment / age Less than 4 years > Behavioral scale Between 4-6 years > Face scale More than 6 years > VAS or numeric scale Scale type VAS Face Behavior Mild pain 1 - 3 2 1 - 2 Moderate pain 3 - 5 4 3 - 4 Severe pain 5 - 7 6 5 - 6 Very severe > 7 8 - 10 7 - 10 Painkiller 3/10 4/10

Different types of painkillers Level Painkiller 1 Paracetamol 2 Codeine Non Steroid Anti-inflammatory Tramadol 3 Morphine

How to chose painkiller Level 1 & 2: can be administrated by the nurse (triage nurse) Level 3: medical prescription only Association between different levels is possible (ex: 1 + 2 or 1 + 3) No pain Mild pain Moderate pain Severe pain Very severe pain No use Level 1 Level 1 or 2 Level 2 or 3 Level 3

Level 1 = Paracetamol DOLIPRANE / EFFERALGAN Dose 15mg/Kg by mouth (better than intra-rectal) < 5 Kg Doliprane 100mg ½ sachet 5 – 8 Kg 1 sachet 8 – 12 Kg Doliprane 150mg 12 – 16 Kg Doliprane 200mg 16 – 27 Kg Doliprane 300mg > 27 Kg Dopirane 500mg

Level 2 : Codeine CODENFAN 0.5ml/Kg/6h (soon available in FVH) EFFERALGAN Codeine (only if > 15Kg) Weight Posologie 15-22 Kg ½ tablet / 6h 23 – 30 Kg ½ tablet / 4h 31 – 50 Kg 1cp / 4 to 6h > 50 Kg 1 to 2 tablets/ 4h

Level 2 : Tramadol Authorized for children of 15 years old or more 1 tablet /every 6 hours Association with paracetamol possible There is a sirup of tramadol (Topalgic 100mg/ml for children > or = 3 years) but not available in FVH…

Level 2 : Non Steroid Anti-inflammatory = Children’s Ibrafen® sirup If needed, repeat dose every 6 hours Age Weight (Kg) Dose (teaspoon) Under 2 <11 Kg 1/2 2 - 3 11 - 16 1 4 – 5 16 - 21 1.5 6 – 8 21 - 27 2 9 – 10 27 - 32 2.5 11 32 - 43 3

Level 3 : Morphine IV Indicated if severe or very severe pain Use only if medical supervision (Pain, consciousness, respiratory rate) Ventilation device available (balloon, high concentration mask, Oxygen) and Naloxone available. Contre-indication: hepatic failure, asthma in crisis, cranial trauma, hypersensitivity to morphine

Management of morphine Use bolus of morphine (titration) First dose : 0.1mg/Kg IVD (always < 5mg) Reevaluation every 5 minutes (use the same scale) Reinjection of 0.025mg/Kg every 5 to 7 minutes if EVA > 4 (objective = EVA < 4) There is no maximum dose but medical assessment is necessary after 5 injections

Preparation of morphine 1 ampoule of morphine = 10mg Dilute the ampoule in 9ml of serum  You get 10mg / 10ml (1mg/1ml) First dose 0.1mg/Kg Example: child 20Kg > needs 2mg = 2ml of the diluted preparation. Next bolus 0.025mg/Kg > 0.5mg = 0.5ml

Safe control during morphine treatment : 3 criteria Re-assessment of the pain Conscious evaluation (sedation score) Respiratory Rate Score Sedation Clinical signs No sedation Alert, eyes opened 1 Mild sedation Eyes open on demand 2 Important sedation Eyes open on stimulation 3 Very severe Impossible to wake up

Respiratory depression Respiratory rate is the best criteria with consciousness Age Respiratory Rate < 1 year > 20/min. 1 to 5 years > 15/min. > 5 years > 10/min.

In case of overdose signs Sedation score < 2 and RR to law (depend of age) Stimulate the child and ask him to breath Oxygenation with high concentrated mask if SaO2 < 94% 6 to 8l/min If no improvement after stimulation, use Naloxone (NARCAN®)

Use of Naloxone = NARCAN® 1 ampoule = 0.4mg = 400g = 1ml Posologie: 1 to 2 g / Kg IVD Dilute 1 ampoule of 1ml in 9 ml of serum  Inject 1ml by 1ml until the child recover normal conscious & respiratory rate Problem: the antalgic effect of morphine is removed

Criteria of discharged after use of morphine in children Only after 2 hours of surveillance in A&E (after the last bolus of morphine) Child awake (sedation score = 0) Respiratory rate normal for the age Parents agree for assessment at home (give and explain special form for assessment after use of morphine)