Paediatric Acute care Guidelines PMH Emergency Department

Background

  • Painful medical conditions and injuries in children are a common presentation to emergency
  • Pain is often undertreated in children
 

Assessment

  • Older children can use visual analogue scales to self report pain
  • Physiological and behavioural parameters can be used in patients of all ages to assess pain
  • Reassessment of pain is important after providing analgesia
 

Management

  • Non pharmacological strategies are an important adjunct to medications
  • Analgesics should be prescribed according to pain intensity
  • Local anaesthetic and nerve blocks provide effective analgesia in suitable patients

Further management

  • Distraction techniques such as blowing bubbles, singing and story telling are a useful adjunct to analgesic medications especially during painful procedures
  • Sucrose may used in infants for procedural pain 
  • Painful lacerations may be managed with topical local anaesthetic preparations such as Laceraine and ALA or local anaesthetic infiltration 
  • Femoral fractures and hand or foot injuries may be adequately analgesed by a nerve block  

Medications

Doses for Commonly Used Analgesics for Children in the ED

Mild to Moderate Pain

Sucrose

  • For babies aged < 3 months
  • Dose:  Start with 1ml of 25% sucrose 2 minutes prior to procedure.  Continue giving small volumes of sucrose until procedure is completed or 2 ml MAX dose is reached
  • Onset:  2 minutes
  • Peak effect:  3-5 minutes

Paracetamol

  • Dose:   Oral: 15mg/kg every 4-6 hours (max dose 60 mg/kg daily)
                     Rectal: 15-20 mg/kg (up to 1 g) every 6 hours (round doses to appropriate suppository strength available)
  • Severe pain:   Dose may be increased to 90 mg/kg/day (not to exceed 4g daily) for a maximum of 48 hours
  • Adult dose:  500 – 1000 mg/dose to a maximum of 4 g/day
  • Onset:  20-40 minutes
  • Peak effect:  2 hours
  • Generally well tolerated
  • Intravenous preparation is available for patients who are unable to have oral or PR route

Ibuprofen

  • Age:  3 months – 18 years
  • Dose:  10 mg/kg/dose 6-8 hourly (adult 400 mg/dose) orally
  • Max daily dose:   30 mg/kg to max of 2.4g
  • Onset:  30 minutes
  • Peak effect:  60-90 minutes
  • May cause GI upset – give with or soon after food if possible

Painstop Day-time 

*A recent TGA review has recommended avoiding codeine in children < 12years and in children <18 post adenotonsillectomy for obstructive sleep apnoea. PMH pharmacy is currently reviewing codeine use ay PMH and this guideline will be updated accordingly [December 2015] 

    • Paracetamol – 120mg per 5mL
    • Codeine Phosphate- 5mg per 5mL
       
  • Dose:  0.8 mL/kg/dose, 4-6 hourly
  • Maximum Dose:  30ml,  to a maximum of 4 doses per 24 hours orally
  • Be aware of potentiation when combined with other sedative agents
  • PMH does not advocate the use of Painstop Night

Moderate to Severe Pain

Oxycodone (oral)

  • Age:   >12 months age
  • Dose:  0.05 – 0.1mg/kg/dose every 4 hours (Adult dose 5-15mg) orally 
  • Onset:  15-30 minutes
  • Peak effect:  1 hour
  • Monitor respiratory depression

Intra Nasal Fentanyl

  • Age:  1-18 years
  • Dose:  1.5 micrograms / kg intranasally
  • Onset:  2 minutes
  • Peak effect:  5-10 minutes
  • Preferred potent analgesic in patients without IV access

Morphine (intravenous)

  • Dose:
    • Age: Less than 12 months – 0.05mg/kg to max dose equivalent to 0.1 mg/kg every 2-4 hours
    • Age: Over 12 months – 0.05mg/kg to max dose equivalent to 0.2 mg/kg every 2-4 hours
  • Onset:  5-10minutes
  • Peak effect:  15-30minutes
  • Monitor for respiratory depression, hypotension

Opioids should rarely be given without a simple analgesic such as paracetamol which provides adjunctive pain relief

 

Nursing

  • Pre and ongoing post analgesia pain scores 
  • Analgesia administered to a patient for moderate to severe pain will require baseline observations of HR, Resp, oxygen sats and BP
  • Refer to specific drug administration guidelines for Intra-nasal Fentanyl and Morphine nursing considerations
  • PMH staff can refer to Nurse Initiated Analgesia Guidelines 

References

PMH ED Guideline: Analgesia – Last Updated: July 2014
AMH Children’s Dosing Companion (online). Adelaide: Australian Medicines Handbook Pty Ltd; 2014 July. Available from: https://childrens.amh.net.au
Codeine use in children after tonsillectomy and/or adenoidectomy: Retrieved from http://www.australianprescriber.com/magazine/37/2/61/3, 6 August 2014

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