Pain management in children

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Pain management in children

• Dr David Tran
• FVHospital
• AE depatment

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Pain evaluation

• Each child coming in AE 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)

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Face pain scale / Visual Analog Scale / Verbal
descriptor scale
0 1 - 2 3 - 4 5 - 6 7 - 8 9 - 10
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Pain assessment in infants
0
1 - 2
3 - 4
5 - 6
7 - 10
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Pain assessment / age

• Less than 4 years gt Behavioral scale
• Between 4-6 years gt Face scale
• More than 6 years gt 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 gt 7 8 - 10 7 - 10
Painkiller 3/10 4/10 3/10
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Different types of painkillers
Level Painkiller
1 Paracetamol
2 Codeine Non Steroid Anti-inflammatory Tramadol
3 Morphine
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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
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Level 1 Paracetamol

• DOLIPRANE / EFFERALGAN
• Dose 15mg/Kg by mouth (better than intra-rectal)

lt 5 Kg Doliprane 100mg ½ sachet
5 8 Kg Doliprane 100mg 1 sachet
8 12 Kg Doliprane 150mg 1 sachet
12 16 Kg Doliprane 200mg 1 sachet
16 27 Kg Doliprane 300mg 1 sachet
gt 27 Kg Dopirane 500mg
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Level 2 Codeine

• CODENFAN 0.5ml/Kg/6h (soon available in FVH)
• EFFERALGAN Codeine (only if gt 15Kg)

Weight Posologie
15-22 Kg ½ tablet / 6h
23 30 Kg ½ tablet / 4h
31 50 Kg 1cp / 4 to 6h
gt 50 Kg 1 to 2 tablets/ 4h
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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 gt or 3 years) but not available in
  FVH

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Level 2 Non Steroid Anti-inflammatory
Childrens Ibrafen sirup

• If needed, repeat dose every 6 hours

Age Weight (Kg) Dose (teaspoon)
Under 2 lt11 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
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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

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Management of morphine

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

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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 gt needs 2mg 2ml of the
  diluted preparation.
• Next bolus 0.025mg/Kg gt 0.5mg 0.5ml

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Safe control during morphine treatment 3
criteria

1. Re-assessment of the pain
2. Conscious evaluation (sedation score)
3. Respiratory Rate

Score Sedation Clinical signs
0 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
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Respiratory depression

• Respiratory rate is the best criteria with
  consciousness

Age Respiratory Rate
lt 1 year gt 20/min.
1 to 5 years gt 15/min.
gt 5 years gt 10/min.
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In case of overdose signs

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

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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

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Criteria of discharged after use of morphine in
children

• Only after 2 hours of surveillance in AE (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)