pediatric pain management in an anti-opioid environment: challenges and resources · 2018-09-18 ·...
TRANSCRIPT
Pediatric Pain Management in an Anti-Opioid Environment Challenges and Resources
Phyllis L Hendry MD FAAP FACEP
Term Professor of Emergency Medicine and Pediatrics
Assistant Chair for Research Dept of Emergency Medicine
University of Florida College of MedicineJacksonville
Trauma One Deputy Medical Director Pediatric Transport
PI Pain Assessment and Management Initiative (PAMI)
Phyllis L Hendry MD FAAP FACEP
Pediatric Pain Management in an Anti-Opioid Environment
Challenges and Resources
FINANCIAL DISCLOSUREI have no relationship with a
commercial supporter
UNLABELEDUNAPPROVED USES DISCLOSURE None
Learning Objectives
1 Describe a stepwise approach for managing pediatric pain and sedation based on setting situation development and family
2 Identify factors affecting the individual childrsquos response to pain
3 Discuss advantages of using nonpharmacologic pain management techniques and distraction to decrease opioid dosage save time and improve patient safety
4 Describe current societal trends and challenges in pain management
5 Identify pediatric pain management resources and tools
Learning ObjectivesRapidly Changing Landscape
My Background Why Pain
bull Pediatric
bull EM
bull Trauma
bull EMS
bull Hospice and Palliative Care
bull Professional and personal experiences
bull Education grants and research mutidisciplinary
Why Focus on Pain Management
bull Chronic pain alone affects more Americans than diabetes cancer and heart disease combined
bull Pain is the most common reason for seeking health care and as a presenting complaint accounts for up to 78 of ED visits
bull Pain is often undertreated especially in children women African-Americans and Hispanics
bull Trauma accounts for 28 of pediatric EMS calls but lt1 receive pain medications (PECARN)
bull Why donrsquot we treat pain like any other abnormal VS or disease
BP and glucose example
Pain 101-itrsquos complicated
Pain Assessment and Management Initiative (PAMI)
Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP
Project Manager Raina Davidman LPN EMT MBA
A one-stop free access educational and patient safety project
PAMI mission
Improve pain recognition management and reassessment
Promote opioid stewardship in ED EMS hospital and other settings
Provide learning modules toolkits and resources for providers and patients
2014-present
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Phyllis L Hendry MD FAAP FACEP
Pediatric Pain Management in an Anti-Opioid Environment
Challenges and Resources
FINANCIAL DISCLOSUREI have no relationship with a
commercial supporter
UNLABELEDUNAPPROVED USES DISCLOSURE None
Learning Objectives
1 Describe a stepwise approach for managing pediatric pain and sedation based on setting situation development and family
2 Identify factors affecting the individual childrsquos response to pain
3 Discuss advantages of using nonpharmacologic pain management techniques and distraction to decrease opioid dosage save time and improve patient safety
4 Describe current societal trends and challenges in pain management
5 Identify pediatric pain management resources and tools
Learning ObjectivesRapidly Changing Landscape
My Background Why Pain
bull Pediatric
bull EM
bull Trauma
bull EMS
bull Hospice and Palliative Care
bull Professional and personal experiences
bull Education grants and research mutidisciplinary
Why Focus on Pain Management
bull Chronic pain alone affects more Americans than diabetes cancer and heart disease combined
bull Pain is the most common reason for seeking health care and as a presenting complaint accounts for up to 78 of ED visits
bull Pain is often undertreated especially in children women African-Americans and Hispanics
bull Trauma accounts for 28 of pediatric EMS calls but lt1 receive pain medications (PECARN)
bull Why donrsquot we treat pain like any other abnormal VS or disease
BP and glucose example
Pain 101-itrsquos complicated
Pain Assessment and Management Initiative (PAMI)
Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP
Project Manager Raina Davidman LPN EMT MBA
A one-stop free access educational and patient safety project
PAMI mission
Improve pain recognition management and reassessment
Promote opioid stewardship in ED EMS hospital and other settings
Provide learning modules toolkits and resources for providers and patients
2014-present
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Learning Objectives
1 Describe a stepwise approach for managing pediatric pain and sedation based on setting situation development and family
2 Identify factors affecting the individual childrsquos response to pain
3 Discuss advantages of using nonpharmacologic pain management techniques and distraction to decrease opioid dosage save time and improve patient safety
4 Describe current societal trends and challenges in pain management
5 Identify pediatric pain management resources and tools
Learning ObjectivesRapidly Changing Landscape
My Background Why Pain
bull Pediatric
bull EM
bull Trauma
bull EMS
bull Hospice and Palliative Care
bull Professional and personal experiences
bull Education grants and research mutidisciplinary
Why Focus on Pain Management
bull Chronic pain alone affects more Americans than diabetes cancer and heart disease combined
bull Pain is the most common reason for seeking health care and as a presenting complaint accounts for up to 78 of ED visits
bull Pain is often undertreated especially in children women African-Americans and Hispanics
bull Trauma accounts for 28 of pediatric EMS calls but lt1 receive pain medications (PECARN)
bull Why donrsquot we treat pain like any other abnormal VS or disease
BP and glucose example
Pain 101-itrsquos complicated
Pain Assessment and Management Initiative (PAMI)
Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP
Project Manager Raina Davidman LPN EMT MBA
A one-stop free access educational and patient safety project
PAMI mission
Improve pain recognition management and reassessment
Promote opioid stewardship in ED EMS hospital and other settings
Provide learning modules toolkits and resources for providers and patients
2014-present
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Learning ObjectivesRapidly Changing Landscape
My Background Why Pain
bull Pediatric
bull EM
bull Trauma
bull EMS
bull Hospice and Palliative Care
bull Professional and personal experiences
bull Education grants and research mutidisciplinary
Why Focus on Pain Management
bull Chronic pain alone affects more Americans than diabetes cancer and heart disease combined
bull Pain is the most common reason for seeking health care and as a presenting complaint accounts for up to 78 of ED visits
bull Pain is often undertreated especially in children women African-Americans and Hispanics
bull Trauma accounts for 28 of pediatric EMS calls but lt1 receive pain medications (PECARN)
bull Why donrsquot we treat pain like any other abnormal VS or disease
BP and glucose example
Pain 101-itrsquos complicated
Pain Assessment and Management Initiative (PAMI)
Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP
Project Manager Raina Davidman LPN EMT MBA
A one-stop free access educational and patient safety project
PAMI mission
Improve pain recognition management and reassessment
Promote opioid stewardship in ED EMS hospital and other settings
Provide learning modules toolkits and resources for providers and patients
2014-present
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
My Background Why Pain
bull Pediatric
bull EM
bull Trauma
bull EMS
bull Hospice and Palliative Care
bull Professional and personal experiences
bull Education grants and research mutidisciplinary
Why Focus on Pain Management
bull Chronic pain alone affects more Americans than diabetes cancer and heart disease combined
bull Pain is the most common reason for seeking health care and as a presenting complaint accounts for up to 78 of ED visits
bull Pain is often undertreated especially in children women African-Americans and Hispanics
bull Trauma accounts for 28 of pediatric EMS calls but lt1 receive pain medications (PECARN)
bull Why donrsquot we treat pain like any other abnormal VS or disease
BP and glucose example
Pain 101-itrsquos complicated
Pain Assessment and Management Initiative (PAMI)
Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP
Project Manager Raina Davidman LPN EMT MBA
A one-stop free access educational and patient safety project
PAMI mission
Improve pain recognition management and reassessment
Promote opioid stewardship in ED EMS hospital and other settings
Provide learning modules toolkits and resources for providers and patients
2014-present
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Why Focus on Pain Management
bull Chronic pain alone affects more Americans than diabetes cancer and heart disease combined
bull Pain is the most common reason for seeking health care and as a presenting complaint accounts for up to 78 of ED visits
bull Pain is often undertreated especially in children women African-Americans and Hispanics
bull Trauma accounts for 28 of pediatric EMS calls but lt1 receive pain medications (PECARN)
bull Why donrsquot we treat pain like any other abnormal VS or disease
BP and glucose example
Pain 101-itrsquos complicated
Pain Assessment and Management Initiative (PAMI)
Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP
Project Manager Raina Davidman LPN EMT MBA
A one-stop free access educational and patient safety project
PAMI mission
Improve pain recognition management and reassessment
Promote opioid stewardship in ED EMS hospital and other settings
Provide learning modules toolkits and resources for providers and patients
2014-present
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pain 101-itrsquos complicated
Pain Assessment and Management Initiative (PAMI)
Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP
Project Manager Raina Davidman LPN EMT MBA
A one-stop free access educational and patient safety project
PAMI mission
Improve pain recognition management and reassessment
Promote opioid stewardship in ED EMS hospital and other settings
Provide learning modules toolkits and resources for providers and patients
2014-present
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pain Assessment and Management Initiative (PAMI)
Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP
Project Manager Raina Davidman LPN EMT MBA
A one-stop free access educational and patient safety project
PAMI mission
Improve pain recognition management and reassessment
Promote opioid stewardship in ED EMS hospital and other settings
Provide learning modules toolkits and resources for providers and patients
2014-present
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Presentation includes materials and resources from the
Pain Assessment and Management Initiative (PAMI) a
free access educational project and website Funding
provided by Florida Medical Malpractice Joint Under-
writing Association Alvin E Smith Safety of Health Care
Services Grant All products are multidisciplinary and
designed to be used or adapted by any health care
facility school or agency
httppamiemergencymedjaxufledu
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
PAMI Stakeholders and Collaborators + Consultants
EMS for Children Program
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
All PAMI tools amp resources are free access and adaptable
bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary
bull Pain Management and Dosing Guide
bull Discharge Planning Toolkit for Pain
bull Patient Educational Videos
bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards
httppamiemergencymedjaxufledu
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
PAMI Module Topics-2 hours free CEUCME each
Basics of Pain Management and
Assessment
Pharmacological Treatment of Pain
Non-pharmacological Treatment Management of Acute Pain
Procedural Sedation and Analgesia Pediatric Pain Management
PrehospitalEMS Management of Pain
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pain The Pendulum Swings the Other Way
bull Total upheaval in the world of pain management
bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain
bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip
bull New methods of treating pain
bull Post op nerve blocks
bull Old drugs used in new ways
bull Growth of pain specialists and procedures
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pain The Pendulum Swings the Other Way
bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids
bull CDC The Joint Commission HCHAPS survey scoring
bull Opioid deaths = MVCs
bull Focus shifting to abusers of the system versus those in real pain- how to balance
bull State prescription drug monitoring programs legislation
bull Pain MCI
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
1Information Management in EHRs
2Unrecognized Patient Deterioration
3Implementation and Use of Clinical Decision
Support
4Test Result Reporting and Follow-Up
5Antimicrobial Stewardship
6Patient Identification
7Opioid Administration and Monitoring in
Acute Care
8Behavioral Health Issues in Non-Behavioral-
Health Settings
9Management of New Oral Anticoagulants
10Inadequate Organization Systems or
Processes to Improve Safety and Quality
2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Challenges- Keeping Balance
bull Rapid influx of new literature
bull Most opioid deaths and ODs are now from nonprescribed or illegalsources
bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities
bull Analgesic shortages
bull Multimodal management options
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Why Is Pediatric Pain Management So Important
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Examples of Common Painful Pediatric Procedures Include
Orthopedic proceduresFx
reduction
Burn amp wound debridement
Cardioversion endoscopy or bronchoscopy
IV or blood drawLumbar
puncture
Chesttube insertion
Radiographic studies in agitated or uncooperative
patients
Abscess incision amp drainage
Laceration repair
Foreign body removal
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis
Chronic Pain Conditions
bull Cancerbull Rheumatologic
disordersbull Migraine headaches
Adolescents posing a threat to themselves
or staff
Chronic disorders with an exacerbation or new
painful conditionbull Autism plus procedure
bull Oncology patient with a fracture or abscess
Post-operative pain
bull TonsillectomybullOrthopedic procedures
20
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Recurrent pain
Under-treated
pain
Develop-mental factors
Pain memory
Creation of Pain Memory in Children
Coping
Developmental age
Past experience
Temperament
What we do during a childrsquos first painful experience has lasting effects
21
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Other Reasons Pediatric Pain Management Important
bull Early management provides long-term benefits
bull decreased long-term sequela in children
bull prevention of chronic pain through the development of hypersensitized pain pathways
bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc
Sets the trajectory and
tone for future pain
experiences as an
adolescent and adult
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
hellipmedical training in pain
management is scant
Veterinary schools require
ldquoat least five times more
education on how to handle
painrdquo than medical schools Nora D Volkow the director of the
National Institute on Drug Abuse
said earlier this year in testimony
before a Senate committee
Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016
ldquoOne of the best ways to address the
epidemic of chronic pain in this
country is to stop it before it startshellip
If we could reduce painful
experiences in childhood we might be
able to reduce chronic pain in the
next generationrdquo
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Chronic Pain in Children Important link between post-traumatic stress amp sleep
Patrick Finan PhD and Melanie Noel PhD
bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS
bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association
bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference
bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C
P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al
METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect
CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children
Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pediatric ED Pain Scenarios- Huge Spectrum
bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications
bull A 14 yo presents with JRA and severe joint pain
bull A 5 yo presents after fall off monkey bars with obvious deformity of arm
bull An irritable 6 month old presents with a huge abscess and fever
bull A 3 yo presents with burns after pulling pot of boiling water off the stove
28
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Cases I am seeing nowbull 2 yo child of a health care provider
severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction
bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge
bull Mother demanding Rx for fentanyl patches for her sons ankle sprain
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
First Step is Recognition and Assessment of Pediatric Pain
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
The First Step is to Recognize or Anticipate a Painful Condition
bull Children often cannot differentiate between pain and anxiety
bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage
bull Procedures and treatments used to manage the disease or injury may induce pain
31
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Factors Affecting Pediatric Response to Painful Stimuli
bull Age gender ethnicity
bull Socioeconomic and psychiatric factors
bull Culture and religion
bull Genetics
bull Previous experiences
bull Patientfamily perceptions
32
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Elements of Pain Assessment
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized assessment
tool
33
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Consider
bull The childrsquos primary language
bull Words or phrases suggested by the parentcaregiver
bull The childrsquos developmental level
Explore
bull Location of pain
bull Duration of pain
bull Quality of pain
bull Precipitating factors
bull Effect on daily activities
bull Pain relief measures
bull Previous pain experiences
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
34
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED
OPQRSTO ndash Onset of event
bull What was the patient doing when it started Were they active inactive and or stressed
bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic
problem
P - Provocation and palliation of symptoms bull Is the pain better or worse with
bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting
standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of
heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before
bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest
35
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
36
Pain Assessment SOCRATES
Site - Where is the pain Or the maximal site of the pain
Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive
Character - What is the pain like An ache Stabbing
Radiation - Does the pain radiate anywhere (See also Radiation)
Associations - Any other signs or symptoms associated with the pain
Time course - Does the pain follow any pattern
ExacerbatingRelieving factors - Does anything change the pain
Severity - How bad is the pain
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain
37
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Why Children Might Not Disclose Pain
bull Avoidance of painful treatments
bull Fear of being sick
bull Fear of healthcare professionals
bull Protection of parents or caregiver
bull Avoidance of hospitalization
bull Desire to return to activitiesbull Sportsbull Social eventsbull School
38
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Choose an appropriate tool based on the childrsquos
bull Age
bull Cognitive ability and language
bull Condition
bull Institutional preference
bull Use the same pain scale throughout the EMSEDhospital experience
bull Educate the childparentcaregiver about the use of the scale
39
Assess physiologic parameters
Perform behavioral
observation
Question the child
Use standardized
assessment tool
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pain Assessment Scales
bull Pain scales fall into 2 general categories
bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them
bull Self-report scales include selection of a face or color or number to represent pain
40
bull There are different validated pain
scales available for a variety of patient populations
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment
Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)
2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain
Rating Scale (DVPRS)
1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)
Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)
(7-11yrs)8 yo and older
1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)
Numeric Rating Scale (NRS)
Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES
Infant and older1 Revised Faces Legs Activity Cry and Consolability
(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)
(ages 1-7)
Examples of Pain Scales
41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pediatric Non-verbal GCS lt15 or Cognitive Impairment
42
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pediatric Verbal Alert and Oriented
43
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pediatric or Adult Verbal Alert and Oriented
44
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
45
Ann Emerg Med 2018 Jun71(6)691-702
Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain
Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
46
Adult Verbal Alert and Oriented
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pain Management Putting it All Together
bull No Perfect Recipe or ldquoCookbookrdquo
bull No Universal Kid Recipe
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)
Ideal approach not always possible
Step 7 Monitoring amp Discharge Checkpoint
Step 6 Management Checkpoint
Step 2 Developmental or Cognitive Checkpoint
Step 3 Family Dynamic Checkpoint
Step 1 Situation Checkpoint
Step 5 Patient Assessment Checkpoint
Step 4 Facility Checkpoint
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Step 1 Determine the Situation What are you trying to accomplish or manage
bull Pain only
bull Pain and anxiety or agitation
bull Anxiety only
bull Agitation only
bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip
bull Chronic pain condition exacerbation
Determination accomplished after brief triage history exam
Step 1 Situation Checkpoint
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Step 2 Perform a Developmental Checkpoint
bull What is the developmental stage of patient
bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events
bull Regression to lower developmental stage
What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level
Kids and teens donrsquot always follow the charts
Step 2 Perform a Developmental or Cognitive Checkpoint
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Responses to Pain by Age or Development
Age Group Understanding of Pain Behavioral Response Verbal Description
Preschoolers
3ndash6 years (preoperational)
Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away
Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level
Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others
School-Age Children
7ndash9 years (concreteoperations)
Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings
Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining
Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts
10ndash12 years (transitional)
Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)
May pretend comfort to project bravery may regress with stress and anxiety
Able to describe intensity and location with more characteristics able to describe psychologic pain
Adolescents
13ndash18 years(formaloperations)
Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others
Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers
More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Step 3 Family Dynamic Checkpoint
bull Who is with the child- parents siblingshellip
bull Who is the legal guardian
bull Who actually cares for the child
bull Who do you want to deal with
bull Culture past experience
bull What can they tolerate
bull Other priorities- another injured child etc
bull Family personality and stress level
Step 3 Family Dynamic Checkpoint
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Step 4 Facility (AgencyCommunity) Checkpoint
bull Staffing and setting
bull Community rural childrenrsquos hospital
bull Experience
bull Pediatric
bull Team capabilities and expertise
bull Existing hospitalagency policies
bull Acuity and overcrowding of the ED
bull Other priorities- MCI etc
bull Equipment monitoring backup
Step 4 Facility Checkpoint
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Step 5 Patient Assessment Checkpoint
bull Review history assessment and risk factors
bull Chronic illness-previous painful experiences recent surgery
bull Psychiatric and mental considerations
bull Injury severity +- contraindications to opioids or sedation
bull Body habitus
bull Weight- ideal or real Obesity
Step 5 Patient Assessment Checkpoint
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Step 6 Management Checkpoint Choose Your ldquoReciperdquo
bull No magic recipe must individualize and adjust ldquoIngredientsrdquo
bull Pharmacologic ldquoingredientsrdquo
bull Route oral nasal IV nebulized topical nerve blocks
bull Type sucrose NSAID opioids anxiolytics ketamine
bull Nonpharmacologic ldquoingredientsrdquo
bull Everyone needs a little child life 101- distraction music swaddling
bull Engage caregivers and parents- coaching therapeutic language
Always consider nonpharmacologic options +- medications
Will pain duration be short (removal of FB laceration repair) or prolonged (burn)
Step 6 Management Checkpoint
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes
bull Topical amp transdermalbull Nasal nebulized oral IV IM
bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-
opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Pediatric Pain Management- Pharmacologic
bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)
bull Topical
bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine
bull Nerve blocks
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Simple pharmacologic tips that patientsfamilies often forget or misunderstand
bull You can take acetaminophen and NSAIDs together
-check dosage and frequency of administration
-change NSAIDs
-beware of high risk populations
bull Topical medications for back pain
bull Car with 4 flat tires analogy ACPA
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
OTC Options are Overwhelming and Confusing
Patients receive very conflicting messages and want prescriptionsrdquo
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate
Equianalgesic Dose
Recommended STARTING
dose for ADULTS
Recommended STARTING
dose for CHILDREN (gt 6 mo)
Oral IV Oral IV Oral IV Oral IV
Morphine (MSIRreg) [CII] O 30-60 min
D 3-6 h
O 5-10 min
D 3-6 h
30 mg 10 mg 15-30 mg q
2-4 h
2-10 mg q
2-4 h
03 mgkg q 4
h
01 mgkg
q 2-4 h
Morphine extended release (MS
Continreg) [CII]
O 30-90 min
D 8-12 h
mdash 30 mg 10 mg 15-30 mg q
12 h
mdash 03-06 mgkg q
12 h
mdash
Hydromorphone (Dilaudidreg) [CII] O 15-30 min
D 4-6 h
O 15 min D
4-6 h
75 mg 15 mg 2-4 mg q 4
h
05-2 mg q
2-4 h
006 mgkg q 4
h
0015 mgkg
q 4 h
HydrocodoneAPAP 325 mg
(Norco 5 75 10reg) [CII]
Hycet (75 mg325 mg per 15 mL)
O 30-60 min
D 4-6 h mdash 30 mg mdash
5-10 mg q
6 h mdash
01-02 mgkg q
4-6 h mdash
Fentanyl [CII]
(Sublimazereg Duragesicreg)
Patch for opioid tolerant patients
ONLY
Transdermal
O 12-24 h
D 72 h per
patch
O immediate
D 30-60 minmdash
100 mcg
(01 mg)
Transdermal
12-25 mcgh
q 72 h
50 mcg q
1-2 h
Transdermal
12-25 mcgh q
72 h
1-2 mcgkg q 1-2 h (max 50
mcgdose)
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)
Acetaminophen
(Tylenolreg)
325-650 mg
PO q 4-6 h
Max 4 gd or 1 g q 4 h
15 mgkg
PO q 4-6 h
Max 90 mgkgd
Acetaminophen
IV (Ofirmevreg)
Use only if not tolerating
PO
1 g IV q 6 h Max 4 gd or 650
mg q 4 h prn pain
lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain
Max 75mgkgd
Celecoxib (Celebrexreg) 100-200 mg
PO daily to q 12 h
Max 400 mgd
gt2 yo
50 mg PO BID
Ibuprofen (Motrinreg)
400-800 mg PO q 6 to 8 hMax 3200 mgd
10 mgkg
PO q 6 to 8 h
Max 40 mgkgd or 2400 mgd
Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d
05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d
Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd
5 mgkg PO q 12 hMax 1000 mgd
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments
Fentanyl IN 15-2 mcgkg q 1-2 h
Neb 17-3 mcgkg
3 mcgkg or 100 mcg Divide dose equally
between each nostril
Midazolam
(5 mgmL)
IN 03 mgkg 10 mg or 1 mL per
nostril (total 2 mL)
Divide dose equally
between each nostril
Ketamine See Ketamine table
Lidocaine Neb 4 (40 mgmL)
100-200 mg or 25-5 mL
45 mgkg total or 300
mg
gt5 mgkg associated with
serious toxicity
Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose
Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg
IM 4- 5 mgkg
Sub-dissociative Analgesia^ IV 01 to 03 mgkg
IM 05-10 mgkg IN 05-10 mgkg
Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Intranasal Medications
bull Use concentrated solution bull Ketamine 50 mgml
bull Fentanyl 50 mcgml
bull Midazolam 5mgml
bull Use an atomizerbull If gt 1ml divide between nares
bull Aim spray toward turbinatespinna
Rapid CSF levels
63
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Ketamine Pharmacology
bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia
bull R(-) vs S(+) ketamine
bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances
bull High lipid solubility
bull allows rapid crossing of the blood-brain barrier
bull quick onset of action (peak concentration at 1 minute-IV)
bull Rapid recovery to baseline
64
61
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Ketamine Timeline1960rsquos
bull Ketamine first synthesized --Calvin Stevens
bull Patented in US as an anesthetic amp sedative in humans
1970rsquos
bull FDA approved for human usemdashprimarily in pediatrics and elderly
bull Battlefield anesthetic during Vietnam War
bull Sedative agent for children
1980rsquos
bull Decline in use due to increased illicit use and emergence reactions
bull Ketamine first used to treat pain-1989
1990rsquos
bull Ketamine declared a Schedule III Drug controlled substance in the US
2000rsquos
bull Increased
use in
treatment of
acute amp
chronic pain
bull Ketamine as
treatment for
depression
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management
bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)
bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Step 7 Monitoring And Discharge Checkpoint
bull Joint Commission standards
bull Document reassessments
bull Child should be back to baseline and tolerating fluids at discharge
bull Falls prevention
bull Transportation
bull Discharge planning and instructions
bull Pain plan
Step 7 Monitoring amp Discharge Checkpoint
67
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment
Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Discharge Resources
bull httpskidshealthorgenparentsopioid-prescription-safetyhtml
bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128
bull httpswwwtheacpaorg
bull Car with 4 flat tires
bull httpswwwyoutubecomwatchv=5RIii6OUK2A
69
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Discharge Planning Toolkit for Pain
Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo
Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home
without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC
instructions
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
New Emphasis on Nonpharmacologic Methods of Treating Pain
Painting Analogy
Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color
(PEM Playbook httppemplaybookorgpodcastpediatric-pain
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
New Emphasis on Nonpharmacologic Methods of Treating Pain
bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may
bull improve assessment
bull decrease or avoid the use of opioids or anxiolytics
bull decrease time and recovery for procedures
bull decrease adverse events
Laceration example- distraction wound glue fan +-nasal midazolam
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Using Nonpharmacologic Methods to Manage Pain and Anxiety
Development of a Distraction Toolbox
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda
830-900 Registration
900-1000 Basics of ED and EMS Pain Management
bull Opening Pediatric and Adolescent Case Scenarios
bull Background of Pain Management in ED and EMS
bull PAMI Stepwise Approach to Pain Management
bull Responses to Pain by Developmental Stage
bull Overview of Pharmacologic Pain Management
bull Question amp Answer
1000-1100 Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral
Interventions
bull PhysicalSensory Interventions
bull Distraction Toolbox Development
1100-1115 Break and Distribution of Distraction Toolboxes
1115-1215 Putting It All Together-Program Implementation Resources and Evaluation
bull Case Scenario Discussion
bull Educational Resources Supplies and Videos
bull Implementation in your Community
bull EMS Week
bull Community Resources and Networking Opportunities
bull Feedback and Questions
bull Name This Course
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Nonpharmacologic Pain Management
bull Conversation and Therapeutic Language
bull Coaching and Preparation
bull Psychological and Cognitive Behavioral Interventions
bull PhysicalSensory Interventions
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39
Language to Avoid Language to Use
You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)
This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)
The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad
and nexthellip (sensory and procedural information)
You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)
It will feel like a bee sting (negative focus) Tell me how it feels (information)
The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other
familiar time for child) (procedural information positive focus)
The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information
positive focus)
Tell me when you are ready (too much control)When I count to three blow the feeling away from your body
(coaching to cope distraction limited control)
I am sorry (apologizing) You are being very brave (praise encouragement)
Donrsquot cry (negative focus) That was hard I am proud of you (praise)
It is over (negative focus)You did a great job doing the deep breathing holding stillhellip
(labelled praise)
Suggested language for caregivers parents and healthcare providers
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)
It might feel like a pinch (sensory information)
I am sorry (apologizing)You are being very brave (praise encouragement)
Tell me when you are ready (too much control)
When I count to three blow the feeling away from your body (coaching to cope distraction limited control)
You are acting like a baby(criticism)
Letrsquos get your mind off of it tell me about that moviehellip(distraction)
Suggested Language
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Categorization of NonpharmacologicInterventions
Physical (Sensory) Interventions
Positioning
Cutaneous stimulation
Nonnutritive sucking sucrose
Pressure
Hot or cold treatments
Others
Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo
Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Cognitive Development
bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning
bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Comfort Positioning
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Comfort Positioning
bull Why use positioning for comfort
bull Sitting position promotes sense of
control and reduces anxiety
bull Puts child in a secure comforting hold
bull Promotes close contact with caregiver
bull Provides caregiver with an active role
May be prohibited in trauma patients
requiring immobilization and transport
74
Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Cold Therapy for Musculoskeletal Injuries
Rest
Ice
Compression
Elevate
Splinting
Dressing
PositioningIce or cold packs reduce swelling and pain in strains
sprains and fractures Do not put directly on bare skin
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Cognitive-Behavioral Techniques
Types of Cognitive-Behavioral Interventions
Psychologic preparation education information
Distraction (passive or active) Video games TV movies phone
Relaxation techniques (breathing meditation etc)
Music
Guided imagery
Training and coaching
Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
DistractionDistraction is the most common type of cognitive-behavioral method
Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level
Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children
ldquocannot attend to more than one significant stimulus at a timerdquo
Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)
Why use distractionDoes not require advanced training for providers
Works with all developmental levels
Involves parents and caregivers during stressful times
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Two Types of Distraction
Passive Distraction - attention redirected to a pleasurable stimulus or object
bull Storytelling
bull Showing a toy
Active Distraction - encourage participation in activities during procedure
bull Blowing bubbles
bull Playing a game
bull Interacting with electronic device
Can be used together or alone
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom
Distraction is more than ldquorainbows and butterfliesrdquo
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Conversation and Distraction
To learn more visit
httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-
starters-alternative-paihtml
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Guided Imagery
bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience
bull Helps patients use their imagination to create a descriptive story
bull Guided Imagery Options
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
76
Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off
pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain
switch and turn down level of pain to a more comfortable level
Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to
breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask
patient to associate their pain with a color then view the painful part of
their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon
Option 3- Symbolic imagery can be used in adults and adolescents If a
patient with severe arthritis pain complains of pain in one joint ask them
to think about how the pain feels Does it feel like a knife Imagine
pulling the knife out and throwing it away Focusing on an affirmation can
also help ldquoI am removing the knife and throwing it awayrdquo
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Music Therapy
bull Additionally benefits parents and health care providers caring for the anxious patient
bull Many larger hospitals have music therapists or volunteers
Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport
bull Ways to implement
bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Designing Your Distraction Toolkit
bull Components
bull Safety
bull Setting
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Distraction amp Nonpharmacologic Toolkit
bull Reduces anxiety amp pain
bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines
bull ED EMS Trauma Center Radiology suites PICU others
bull Three hour pilot course apps and toolbox components available online
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Distraction Toolbox Components
Rubikrsquos cube
Glitter iSpy wand
Hotcold packs DistrACTION Cards
LED keychains
Pacifier amp Sucrose Water
ldquoOink Oinkrdquo
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Distraction Toolbox Components
Liquid-in-motion
Lighted amp motion toy
Stress Balls
Mad Libs
Wikki Stix
Buzzy ndash cold numbing vibrating
Stickers
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Patient Safety Considerations
bull Infection Controlbull Individual use- child keeps or disposes of the item
(teddy bear pacifiers teethers Wikki Stix ice packs)
bull Multiple use items ensure item can be sanitized (local policies)
Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)
bull Choking Hazardsbull Make sure item is age appropriate
bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)
bull Ensure items with gel or liquid ingredients are nontoxic
Beware of siblings or other children in the room
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Nonpharmacologic Measures Preschoolers
bull Provide calmest environment possible
bull Cold or hot packs
bull Allow position of comfort if safe
bull Light touch or massage
bull Music or video on phone or iPad
bull Stress ball pinwheels bubbles
bull Toys with lights and sounds
bull Distraction cards find objects
bull Look at or read storybooks
bull Singing or storytelling
bull Distracting conversation
bull Coach child through the process
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Resources Literature Videos Websites Apps Vendors and More
bull Many excellent resources available bull PAMI website includes a list of resources
and references bull Let us know if you have suggestions or see
something new
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
The Power of Videos and Cute Kids
Managing Procedural Anxiety in Children
httpwwwnejmorgdoifull101056NEJMvcm1411127
It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps
Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
BreathingRelaxa-tionImagery
Age Development
Tips for Use Cost
YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo
Free
Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger
Free
Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel
Free
Healing Buddies Comfort Kit
4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages
Free
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Virtual Reality
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Virtual Reality
bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety
bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers
bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting
bull Wound care infusions procedures labor and delivery
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Virtual Reality for Pain Management amp Distraction
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Parting Thoughts- Beware ofhelliphelliphellip
bull Drug seeking parents
bull Pregnant and postpartum patients in pain andor at risk for addiction
bull Extrapolation of adult pain management procedures to children
bull Analgesic medication errors due to drug shortages
bull Falls and driving after sedation procedures or pain medications
bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip
bull Profiling and stereotyping (GSW and SSD examples)
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Futurehelliphelliphellip
bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc
bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum
PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
CHFM Survey ResultsDo we want a pediatric survey
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617
Questions and Comments
References and resources can be found on the main PAMI website
httppamiemergencymedjaxufledu
Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu
phyllishendryjaxufledu
(904) 244-4072 or 244-8617