Spotlight on Pediatric Emergency Care Volume 2, Issue 4, July 2004 Children in Pain: We Can Do Better It's a beautiful Saturday afternoon--the kind of day when you just know kids are going to get into trouble. And you're right. Jane, a 6 year-old girl who just fell off the monkey bars, comes in with her very distraught mom. Jane is holding her left arm, crying and upset. It's obvious in triage that Jane has a mildly angulated fracture of her forearm. What should happen next? The way Jane's care gets handled, from this initial encounter forward, will make a huge difference in both Jane's level of comfort, and her mother's perception of the entire emergency department experience. The Big Picture       How does your emergency department staff respond to patients in pain? In this issue, I'll discuss a few specific techniques and modalities useful for helping children in pain, but the starting point must be a global awareness for all staff that pain, in both children and adults, is a very high priority and as such, must be addressed as rapidly and effectively as possible. Of course, with a busy emergency department's competing priorities, properly addressing pain is always a challenge. I would argue that short of an arrest or a critically ill patient, addressing moderate to severe pain is the priority. Over the years, I have found that one of the best tests to gauge what to do when you're unsure is to think about what you would want to happen if it were your family member in pain. If one of my children were in significant pain in an emergency department, I would insist that relief be offered. And I'd expect the same level of respect and professionalism from myself when working as an emergency physician. However, the onus falls on leadership to create a culture that focuses on effective pain management strategies. Initial Strategies       Back to Jane. While it is likely that she will eventually need sedation and fracture reduction, the initial issue for Jane and her mother is Jane's severe discomfort. It can be very challenging to separate pain from anxiety in young children. And the younger the child, the more difficult it is. Jane is old enough to let us know her arm really hurts; we might not get this information from a 2 year old. We need to use common sense here, and simply assume that a young child presenting with a significant injury is likely in significant pain. And we need to treat that pain quickly. Narcotic analgesics still are probably the most effective way to rapidly help alleviate pain for a patient like Jane. A good starting point is to quickly get Jane through the triage process and into an examination room. Ideally, the nurse or child-life specialist can use distraction techniques while Jane's IV is placed, although it is certainly possible that she simply may be in too much pain, or too anxious, to gain much benefit from distraction before pain reduction. As soon as the line is placed, she should be given an intravenous analgesic, such as Morphine Sulphate, at a dose of 0.1 mg/ kg. Dosing is a good example of where things can go astray, especially when working with children. First, children often receive less than adequate doses of analgesics. Generally, it is always appropriate to start with the dose above, and then reassess the patient in 10 minutes. If adequate analgesia has not been obtained, a repeat dose may be given. In addition, it is now worth trying again to help the child with distraction techniques, ranging from TV if available, to stories or music. Distraction techniques may become more effective as some pain relief is achieved. It is also important to splint the extremity in a temporary fashion as early as possible to reduce movement in the affected extremity, a major cause of pain. Ideally, pharmacologic analgesia and splinting should take place before the patient visits radiology. Definitive Management       It is impossible to address the myriad of ways that Jane's and others' injuries might be handled in different types of emergency departments. Jane might need sedation and analgesia for a fracture reduction. Other patients, such as those simply requiring suturing, also may need focused attention on their pain and anxiety. So instead, I want to highlight some basic principles. In some departments, assuming a neurologically and vascularly intact injury, Jane may be sent home with rapid follow-up to the orthopedist for reduction. It is essential that a good splint be placed to help minimize movement, and pain. I comment on discharge analgesics below. In other departments, Jane may undergo reduction in the emergency department. This is a time of high anxiety for both patient and family. Whether using ketamine, etomidate or other agents, it is essential to take the time to fully explain to the family exactly what will be taking place. In the world of pediatrics, we refer to this as "anticipatory guidance." An excellent example of this is explaining that when using ketamine, the eyes often remain open and may appear to wander rapidly (i.e., nystagmus). Without guidance, a parent may become extremely anxious to see this unexpected event happening in their child. LET (lidocaine-epinephrine-tetracaine) gel has markedly improved the suturing experience for children. LET gel tends to work best in the scalp and face, but may also be effective on other parts of the body. It is essential that it be applied generously, and allowed to remain on the laceration for at least 30 minutes. While this often completely eliminates pain at the injury site, buffered lidocaine, infiltrated slowly with a small needle, may augment and extend analgesia. Once the patient is ready to go home, be sure to address the need for discharge pain control. It is very common to under-medicate and/or under-dose oral analgesics. A patient like Jane, with a significant fracture, should be discharged with a short course of a narcotic analgesic, such as acetaminophen with codeine. Again, it is important to ensure that the patient receive an appropriate dose of the codeine component. After a couple days, it may be sufficient to switch to a non-steroidal anti-inflammatory agent, such as ibuprofen. Conclusion       I have just scratched the surface of a huge, and at times, controversial topic. However, you can be sure that if you work to create an environment that truly values addressing pain issues in children, it will make a world of difference for pediatric patients and their families. With this culture in place, it is then a matter of creating appropriate policies and protocols that ensure your ED is the place where your family members would want to come when faced with a painful illness or injury. And when that happens, word will spread in the community that your ED is the place to go for great care! About Our Organization Created in 2003, Petrack Consulting is dedicated to helping physician and hospital leadership bring excellence to emergency services for children. We work collaboratively to fully understand our client?s needs, and then address programmatic initiatives with measurable outcomes. Our unique background in pediatric emergency medicine, administrative medicine, and organization development allows us to create uniquely effective solutions for enhancing emergency services for children.