Pediatric Prehospital Pain Management: the ED perspective

Emergency Medicine Symposium

October 3, 2008

Michael K. Kim, MD, FAAP

Pediatric Emergency Medicine

UWSMPH

Objectives

• Historical model

• Barriers prehspital and ED

• Evidence based advances and future

Reference case

Your 5 year old son Johnny falls off the backyard jungle gym and has a deformed arm. Patient has an IV started and receives 2 mg of morphine in route.

Issues

• Head injury

• Unable to obtain vital signs

• Prolonged transport

• morphine versus fentanyl– routes of administration

• Role of accepting MD/medical control– Level of transport service– Factors for additional doses

Advancement in pre-hospital care

• “scoop and run” – GTHTTH

• “stay and play”

• “play and run”

Pre-hospital

• 14.5 million EMS transports annually– Moderate to severe pain in 20%– 50% are children – McLean SA, PEC, 2002

• Only 6 papers prehospital pain management (1980-1996)

• Challenges and barriers in prehospital setting– Consent– Methodology

Statements

• “Relieving discomfort may be the most important task EMS providers perform for majority of their patients.” ACEP 1997

• “Relief of discomfort is the most relevant outcomes measure for majority of pre-hospital conditions” EMSOP / NHTSA 1999

• Assess for circulation and sensation • Check for other injuries• Age appropriate pain assessment 8/10• Screams with attempts to splint• Imagery, start IV, fentanyl• 5 minutes later, pain score is 3/10• Arm is splinted with minor discomfort • Gently placed in the rig and slow ride to ED• Reassessment before ED; pain score 2/10

In the perfect world…

Prehospital opioid administration for fractures

Prehospital ED

White 1999 Adults 1.8%

McEachin 2002 Adults 18.3% 91.1%

Hennes 2003 Adults 10.5%

children 3.0%

Swor 2005 Adults 26.3% 87.8%

children 21.2% 91.1%

Time to first dose of opioid

Pre-hospital ED

Swor 2005 22 min 88 min

Silka 2002 109 min

Hennes 2006 (unpublished data) 17 min 57 min

Scoop and run result in significant delay in analgesic administration.

Pain Management Barriers

• Provider barriers

• System barriers

• Patient barriers

Survey dataHennes, et al. Prehospital Emerg Care 2005;9:32-39

• Reasons for withholding morphine in children– Inability to assess pain– Patient refusal– Drug seeking behavior– No indications for vascular access

Common assumptions & attitudes

• There is given amount of pain for given injury• Newborn babies do not feel pain• Children have no memory of pain • Children metabolize opioid differently• Children may become addicted to narcotics• Pain is character building• Use of pain medication is sign of weakness• No pain, no gain

Provider barriersKim et al. 2006 NAEMSP abstract

• Doubts the need for pain management• Lack of education

– Pain physiology & pharmacology

• Difficulty in pain assessment– Lack of easy to use assessment tool for children– Questions the validity and reliability of tools

• Negative incentives– Need for an IV & difficult IV– Transport time– Work load– Negative feedback from Docs

System barriers

• Lack of education– Physiology, assessment, pharmacokinetics,

outcomes data

• Medical control– Reluctant to provide pain meds – Ricard-Hibbon 1999 & Fullerton-Gleason 2002

• Multiple tiered system– EMT vs. paramedic

Patient barriers

• No pain meds prior to ED (74%) Spedding 1999

– harmful– hospital’s responsibility– not available

• 70% of adults with severe pain did not ask for pain medication Richrd-Hibbon 1999

ED physicians When should EMS provide analgesia?

• based on the obvious deformity it’s so easy….just get a doctor and get the morphine

• Transport time again • What if I have a little finger….put an IV in• depends too on how bad it actually looks• I think if it is obviously deformed they think

they should put an IV in• Don’t they have to call the doctor if they have

an IV?

ED physiciansIs prehospital pain management a benefit?

• Yes– Calmer patients– Expedites evaluation– If it is grossly deformed, no problem

• No– If short transport time– Unable to evaluate– If they mess up…

ED physicians Focus group summary 2004

• Not aware of pain protocols• Limited experience with prehospital pain

management• Pain assessment report is rarely given• It seems easy to OD kids

Evidenced interventions

• Protocol liberalization Pointer et al. PEC 2005

– Online to offline administration of morphine– 2.8% to 19% increase in MS administration

• Education French et al. PEC 2005

– 3 hour educational intervention– Pain med use 20.4% to 24.5%– NP intervention 2.5% to 34.7%– Pain scores 44.5% to 95.4%

Milwaukee Prehospital Pain Management Group

• ‘Impact of an educational module on prehospital pain management in children’

• Targeted Issue Grant by EMSC 2004-2007• PAMPPER (Pain Assessment and Management

for Prehospital Pediatric EmeRgencies)

Reference Case

Consider following issues during the presentation

Q1: Why is prehospital pain management important?

Q2: Initial assessment and intervention?

Q3: Best method of pain assessment?

Q4: Indications for pain management?

Q5: What determines the need for pain medications?

Q6: What medications should be considered?

Q7: Dose and route of administration?

Negative Effects of Untreated Pain

• Interferes with normal bodily function– Increased metabolic rate– Interferes with clotting– Alters immune function

• Emotional stress/Suffering– Anxiety (Fear of unknown)– Powerlessness– Loss of control

Q1: Why is prehospital pain management important?

• Biochemical: stress hormone release – Epinephrine and norepinephrine– Steroids, growth hormone, and glucagon– Increase metabolic rate

• May cause cardiopulmonary instability

• Physiologic– Tachycardia, tachypnea, BP elevation

• Behavioral– Facial grimace– Physical withdraw, kicking– Crying

• The response varies in every patient based on age, development, and prior experience

Pain results in a stress response

• Biochemical: stress hormone release – Epinephrine and norepinephrine– Steroids, growth hormone, and glucagon– Increase metabolic rate

• May cause cardiopulmonary instability

• Physiologic– Tachycardia, tachypnea, BP elevation

• Behavioral– Facial grimace– Physical withdraw, kicking– Crying

• The response varies in every patient based on age, development, and prior experience

Pain results in a stress response

• Biochemical: stress hormone release – Epinephrine and norepinephrine– Steroids, growth hormone, and glucagon– Increase metabolic rate

• May cause cardiopulmonary instability

• Physiologic– Tachycardia, tachypnea, BP elevation

• Behavioral– Facial grimace– Physical withdraw, kicking– Crying

• The response varies in every patient based on age, development, and prior experience

Pain results in a stress response

• Biochemical: stress hormone release – Epinephrine and norepinephrine– Steroids, growth hormone, and glucagon– Increase metabolic rate

• May cause cardiopulmonary instability

• Physiologic– Tachycardia, tachypnea, BP elevation

• Behavioral– Facial grimace– Physical withdraw, kicking– Crying

• The response varies in every patient based on age, development, and prior experience

Pain results in a stress response

The evidence: Opioids decreases the stress response

• Pain and its effects in the human neonate and fetus. Anand KJ. NEJM. 1987;317(21):1321-9.

– A landmark publication that called into question the widely held belief that neonates do not have the neurophysiologic apparatus to experience pain

– Also decreased stress response and decrease morbidity and mortality after major surgery in neonates.

• Neonatal and pediatric stress responses to anesthesia and operation. Anand KJ. Int Anes Clin. 1988 ;26(3):218-25.

– Benefit seen beyond neonatal period

The evidence: Effect of single painful procedure

• Effect of neonatal circumcision on pain response during subsequent routine vaccination. – Taddio et al. Lancet. 1997:349(9052);599-603.– No pain management during circumcision results in

increased pain response at 4-6 months later

• Consequences of inadequate analgesia during painful procedures in children. Weisman et al. Arch Ped Adolesc Med 1998

– Inadequate pain management during spinal tap results in increased pain scores during subsequent procedures

Q1: Why is prehospital pain management important?

Why is prehospital pain management important?

• Decreases pain and suffering

• Provides comfort during transport

• Expedites evaluation and interventions in the emergency Department

• May improve outcome

Most appropriate pain scale for 4 to 16 years

• Faces Pain Scale -Revised –The Faces Pain Scale - Revised: Hicks CL et al.Pain 2001;93:173-183.

–Validated in children“true representation of pain”

“These faces show how much something can hurt. This face (point to the left-most face) shows no pain. The faces show more and more pain (point left to right) up to this one (point to right –most face) it shows very much pain. Point to the face that show how much you hurt now.”

0 2 4 6 8 10

Q3: Best method of pain assessment?

Pre-hospital Pain Interventions

• ABCDEs first

• Nonpharmacologic

• Pharmacologic

Q4: Interventions for pain?

Non-Pharmacologic Pain InterventionsInjury specific

• Rest• Ice• Compression• Elevate• Splinting• Dressing• Positioning

Q4: Interventions for pain?

Non Pharmacologic Pain InterventionsFear and Anxiety reduction

Method Age Description (examples)

Talking All Form of distraction (explanation)

Distraction All Toys, books, music, talking…

Parental presence All Reassurance and familiarity

Patient Control >3y Retains self control

Imagery >3y Imagining being elsewhere

Truth >5y Be honest (this needle will hurt a bit)

Explanation >5y Removes the fear of unknown & announces what to expect

Q4: Interventions for pain?

When non-pharmacologic interventions are not enough?• Reassessment of pain

• Pharmacologic intervention – Continued moderate to severe pain (score 4)

– morphine sulfate

Q4: Intervention for pain?

Q5: What determines the need for pain meds?

Q6: What meds should be considered?

Pharmacologic interventions

• Morphine– Gold standard– IM/IV/SQ

• Fentanyl– Less hemodynamic effects– IM/IV/IN

Wisconsin pain management guideline (EMSC recommendations)

• Assessment: 0-10 faces scale• Interventions: non-pharmacological• If pain score > 4, morphine 0.1 mg/kg• May repeat every 10-15 min up to 10 mg• Only if SBP > 80 in children• Fentanyl per local EMS guideline• Medical control for additional doses

Reference case

Your 5 year old son Johnny falls off the backyard jungle gym and has a deformed arm. Patient has an IV started and receives 2 mg of morphine in route.

Issues

• Head injury

• Unable to obtain vital signs

• Prolonged transport

• morphine versus fentanyl– routes of administration

• Role of accepting MD/medical control– Level of transport service– Factors for additional doses

Emergency Department events: Patient with a fracture

• Without prehospital pain management– Initial evaluation by

nurse and physician– IV start– Pain meds– Radiograph

• With prehospital pain management– Initial evaluation by

nurse and physician– Radiograph

These 2 steps can be eliminated if patient’s pain is adequately controlled

Manipulation of extremity for x-ray

is Painful

Q1: Why is prehospital pain management important?

* ED staff may not be able to evaluate patient immediately!!!

Why is prehospital pain management important?

Implications for the ED

• Awareness of the EMS protocols

• Confidence in EMS providers

• Voice in your EMS system

• Patient advocacy

• Continuum of pain management

Overview

• Prehospital pain management is important and needs improvement.

• EMS providers need expertise of ED providers• ED providers must know the EMD protocols• Pain management is a continuum

“To cure sometimes, to relieve often, to comfort always”

15th century French description of role of physician