- Email: [email protected]
Easing pain in children
Easing Pain in Children Linda Manley,
RN,
"This will only hurt for a moment. .... Children tolerate pain much better than adults." "Narcotics are very dangerous drugs for children and cause addiction."
BSN,
CEN
and reliable pain measurement tools are becoming available. New, better therapies that incorporate both nonpharmacologic and pharmacologic are being implemented. This article will review various aspects of pain control for children in acute care settings. BARRIERS
hese comments represent some of the myths that persist regarding the perception and management of pain in children. Pain control is n o w r e c o g n i z e d as a major international health care issue for adults and children, and pain is the number one health care complaint prompting patients to seek medical attention in the United States. 1,2 Although it is recognized that acute pain serves as a warning that tissue damage has occurred, less is known about a person's physiologic and emotional responses to pain. Pain is a critical problem for pediatric trauma patients. Small children have an immature nervous system and may be more susceptible to intense pain. ~ Significant pain experienced early in life can cause lasting emotional and physiologic damage. 2 Acute trauma, burns, and the procedures and testing associated with treatment, produce pain that disrupts metabolic, autonomic, and thermoregulatory function? Immunologic function was influenced negatively in laboratory animals subjected to acute pain and stress. 4 W h e n pain m a n a g e m e n t has b e e n aggressive, children have been noted to recover from surgery faster. 2 The knowledge of pain is still limited; however, over the past decade, pain management has become a distinct medical specialty--with a body of scientific literature that challenges old beliefs. More valid
130 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Manley
PAIN RELIEF
One of the biggest obstacles to adequate pain relief for children is outdated medical information. Pain management is not routinely incorporated into medical, nursing, and allied health care educational curricula in the United States. Many health care settings do not use a standardized method to routinely assess, document, or treat pain. Infants and young children are at a disadvantage because they are unable to verbalize their discomfort. If the nurse is unaware of or misinterprets their discomfort, it might be falsely assumed that the child does not hurt. 5 Certainly, infants are "expected" to cry in unfamiliar surroundings. An unfounded fear of addiction or adverse effects to narcotic drugs is a c o m m o n misunderstanding for treating children in pain. Studies show pain control in children is often neglected, particularly in the emergency department setting. It has been found that analgesics were used less frequently in children than in adults, the children were often given inadequate dosages, 6 there were significant delays in administering analgesics t o injured children, and poor documentation of the child's response. 7 Narcotics are withheld out of fear of producing respiratory depression and hypotension; however, these side effects are largely dose related and often reversible with naloxone. 2,6,7 ASSESSING
Linda Manley is an EMS coordinator at Children's Hospital, Columbus, Ohio. For reprints write Linda Manley, RN, BSN, CEN, Children's Hospital, 700 Children's Dr., Columbus, OH 43205-2696. Int J Trauma Nurs 1997;3:130-3. Copyright © 1997 by the Emergency Nurses Association. 1075-4210/97/$5.00 + 0 6511185252
TO ADEQUATE
PAIN IN CHILDREN
Assessing and measuring pain in infants and children are difficult tasks, particularly in the preverbal age group. Pain is often assessed using a child's self-report, or by observing behavior and physiologic responses and obtaining a parental report about the child's pain. Self-report and Pain Rating Scales. If the child is able to cooperate, self-reporting is considered the
VOLUME 3, NUMBER 4
Table 1. Pain rating scales Tool Numeric scale
Age
Description
School age
Straight line with
the end points identified as
Poker Chip Tool 12 4-8 yr
"no pain" (0) or 'Worst pain" (10). The child chooses 1-4 poker chips, each of which symbolizes a "piece of hurt." One chip is a "little hurt," whereas four
Table 2. Summary of pain management strategies used for children Nonpharmacologic
Pharmacologic
Distraction Relaxation Positive reinforcement Preparation Others: transcutaneous
Nonnarcotic analgesics:
electrical nerve stimulation, visual imagery, hypnosis
More than 4 yr
"most hurt." Seven facial
expressions are provided, each depicting a degree of pain that correlates with the child's pain
experience.
best indicator of pain. ~ A child who states he or she is experiencing pain should be believed. Self-reports of pain work best if the child is 3 years of age or older. Young children may not understand terms such as pain, discomfort, excruciating, or cramping. They may simply describe the pain as "I hurt," "I don't feel good,':' or simply "Ouch." Children should be encouraged to point to where it hurts, because their language for b o d y areas may not correspond with the examiner's. Verbal children can use self-reports of pain to describe their symptoms and to rate the efficacy of treatment. Several pain rating scales are available for use in children (Table 1); however, no single tool will serve the needs of all children. Some scales require a trained observer to reduce interobserver variability and practice, whereas other scales are dependent on the child's verbal and cognitive development. Behavioral Responses. Observing behavioral changes, particularly in the preverbal child, is a valuable pain assessment tool. Certain behavioral responses (e.g., irritability, crying, screaming, lethargy, moaning, brow furrowing) and motor responses (e.g., arched or rigid body, shuddering, involuntary shaking, or tensed extremities) are associated with
OCTOBER-DECEMBER 1997
ibuprofen, ketorolac
Sedatives: diazepam, midazolam Opioid analgesics: morphine sulfate, fentanyl Transdermal: EMLA TAC LET Transmucosal
chips are the Faces Scale 12
acetaminophen,
pain. Loss of appetite and disturbed sleep patterns may also be associated with pain. Physiologic Responses. Acute pain activates the sympathetic nervous system, which produces an increased heart rate, respiratory rate, blood pressure (due to vasoconstriction), diaphoresis, and mydriasis (dilated pupils). If a child's pain is not treated adequately, peripheral arterial vasoconstriction can decrease the amount of oxygen supplied to peripheral tissues, interfere with skin grafts "taking" for children with burns, and delay w o u n d healing. 3 Parental Reports of the Child's Pain. Parents can be a valuable source of information for assessing a child's pain; however, this source is often neglected. Parents k n o w their child and are sensitive to changes or pain cues in the child's behavior. 9 They can identify behaviors that accurately predict the intensity of their child's pain. 8
PAIN MANAGEMENT
STRATEGIES
A combination of therapeutic strategies are available to relieve discomfort in children. Because nurses spend a great deal of time with the child and family, they should be aware of the multiple options that are available for helping children who need relief from pain. The options can be grouped according to nonpharmacologic and pharmacologic approaches (Table 2 ). Nonpharmacologic Approaches. A number of interventions that can be helpful in reducing procedure-related pain and distress are often overlooked in an acute care setting. Distraction is used to focus the patient's attention and place the pain stimuli in the periphery of awareness. Distraction does not actually decrease pain intensity, but it can decrease
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Manley 131
the associated emotional distress. 1 Distraction works well for preschool and older children. Examples of distracting activities include muscle contraction (such as clenching the fis0, screaming before the pain, conversation (especially humorous), and fantasy. 8 Other ideas include reading colorfully illustrated books, singing, listening to music or songs, and blowing b u b b l e s - - a very popular distracting activity. At one time, staff would inflate latex gloves to make a balloon. This practice is discouraged because children have bitten the inflated fingers, causing the glove to suddenly deflate, obstruct the child's airway, and cause death. The additional danger of latex allergy is becoming more of a threat to sensitive individuals and a concern for all practitioners. As with distraction, relaxation does not reduce the intensity of pain, but can reduce the associated distress. Parents should be encouraged to stay with their children during painful procedures to provide verbal encouragement and touch. Rocking chairs are comforting to both the child and parent, Slow, deepbreathing exercises may be helpful for the older child
Parents should be encouraged to stay with their children during painful procedures to provide verbal encouragement and touch. and should be practiced before a painful procedure, if possible. Anticipating a painful event is anxiety provoking to most children. Giving the child and parents procedural information (what will be done) and sensory information (what it may feel like) may decrease this stress, a For example, the child might be told that "the soap to clean your arm will be cold and a brownish color," or the local anesthetic might feel like a "pinch" or a "prick." Painful procedures should be performed in a room separate from the child's living area w h e n possible to provide the child with a "safe" environment. Positive reinforcement is a relatively simple intervention that is frequently overlooked. The child should be encouraged during the entire painful procedure and rewarded for any positive behavior, even if distressed3 Rewards can take the form of stickers, badges, prizes, "certificate of bravery," or frozen ice treats. Children should never be punished or made to feel ashamed because they were unable to cooperate. Other nonpharmacologic techniques that can
132
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Manley
lessen the perception of pain include transcutaneous electrical nerve stimulation, visual imagery, and hypnosis. Pharmacologic Approaches. Although most children are accustomed to the oral route for medications, this should not be considered in trauma. Oral medications are contraindicated in severely injured patients, such as those with a head injury, and even minor trauma can precipitate vomiting. Recent advances in drug formulations and routes of administration have helped to change the options. Nonnarcotic analgesics, such as acetaminophen and ibuprofen, are the most widely prescribed analgesics for children. Acetaminophen possesses analgesic and antipyretic properties, has an onset of action of 30 minutes, and is useful for mild pain. Acetaminophen is administered orally or rectally, at a dose of 15 mg/kg. 9,i° Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is generally more potent than acetaminophen, but carries more risk of gastrointestinal irritation or bleeding and reversible platelet dysfunction with long-term use.a° Ibuprofen is administered orally, at a dose of 10 mg/kg. Ketorolac is another NSAID that is gaining popularity in pediatric care. It is a potent drug with analgesic properties comparable to morphine sulfate. Ketorolac is the only NSAID that can be administered intravenously, intramuscu]arly, and orally. The dose is 0.5 to 1.0 mg/kg?, l° Sedatives decrease activity and anxiety, thereby facilitating better cooperation with procedures, Sedatives do n o t relieve pain and must be used in conjunction with an analgesic if treating pain. Common sedatives used for children include the benzodiazepines diazepam and midazolam. Benzodiazepines have sedative, hypnotic, amnesic, anticonvulsant, and respiratory depressant effects. 5a° Midazolam is a particularly versatile medication because it can be given via several routes. Morphine sulfate (MS) is considered the gold standard for pain medications. MS is a potent narcotic metabolized by the liver that has analgesic, sedative, anxiolytic, and euphoric effects. 1° MS is indicated for moderate-to-severe pain. It should be used cautiously in neonates because this age group is particularly susceptible to respiratory depression, and the half-life of the drug is prolonged, a° Complications associated with MS are often dose related and include hypotension (as a result of histamine release and vasodilatation), respiratory depression, decreased gut motility, constipation, urinary retention, and biliary spasm. 1° Therapeutic doses only
VOLUME 3, NUMBER 4
rarely result in complications and can be easily reversed with naloxone. Fentanyl is an extremely potent, rapid-acting synthetic narcotic, 100 times as potent as MS. It is rapidly gaining popularity for controlling severe pain in children. 5,1° When given intravenously, fentanyl has a rapid onset of action--3 to 5 minutes, but a relatively short duration of action--30 to 40 minutes, making it an ideal drug for procedural pain. 5 The recommended dose is usually 2 to 3 t.tg/kg given over 3 to 5 minutes intravenously. Fentanyl can result in respiratory depression, apnea, and bradycardia, therefore, the child should be carefully monitored. 5,1° The transdermal and transmucosal routes of drug administration offer distinct advantages for children. These methods are relatively painless and do not require intravenous access. Several medications, including sedatives and narcotics, can be administered via the transdermal and transmucosal routes. Transdermal administration may be particularly effective for children because their skin is thinner and has a relatively rich blood supply, n Neonates
Ketorolac is another NSAID that is gaining popularity in pediatric care. It is a potent drug with analgesic properties comparable to morphine sulfate. have extremely thin skin; therefore, transdermal drugs must be used with greater caution to avoid toxic levels. Examples of common transdermal medications include eutectic mixture of local anesthetics (EMLA), used to reduce procedural pain (e.g., intravenous access, lumbar puncture), and tetracaine, adrenaline, and c o c a i n e p r e p a r a t i o n (TAC); or lidocaine, epinephrine, tetracaine (LET), often used for pain control and hemostasis during laceration repair. Optimal pain control with EMLA and TAC/ LET requires 60 and 30 minutes, respectively. Special care must be taken to avoid contact with mucous membranes and application to areas with limited collateral circulation. The cocaine preparations should be used with particular caution because cocaine toxicity and death can occur if improperly administered. 5 Transmucosal administration is very effective because mucosal surfaces are rich in blood supply and provide for rapid transport of the drug into the
OCTOBER-DECEMBER 1997
systemic circulation. This route avoids degradation of the drug by first-pass hepatic metabolism. 11 Transmucosal sites include the respiratory tract, nasal cavity, sublingual buccal membranes, and rectum. Drug absorption for each route is dependent on the volume and concentration of the drug, contact time, venous drainage of the particular mucosal tissue, and the drug pharmacokinetics.
SUMMARY The assessment and management of pain in children has been essentially ignored until recently. Thankfully, these "dark ages of pain" are ending. The trauma nurse is an integral part of the pain management team and can have a positive impact on outcome by using a combination of relatively simple strategies. These include using multiple types of assessment to measure the severity of pain; providing adequate pain relief with a combination of pharmacologic and nonpharmacologic interventions; and carefully monitoring and documenting the efficacy of all pain management approaches. REFERENCES 1. Anderson CTM, Zeltzer LK, Fanurik D. Procedural pain. In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents. Baltimore: Williams & Wilkins; 1993.p.435-8. 2. Schrof JM. Easing hurt in small bodies. US News & World Report 1997;(March):60-2. 3. Carr, Osgood, Szyfelbein. Treatment of pain in acutely burned children. In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents. Baltimore: Williams & Wilkins; 1993.p.495-504. 4. Leibeskind JC. Pain c a n kill. Pain 1991 ;44:3-4. 5. Selbst SM, Henretig FM. The treatment of pain in the emergency department. Pediatr Clin North Am 1989;36:965-78. 6. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: patterns of analgesic utilization. Pediatrics 1997;99:711-4. 7. Friedland LR, Pancioli AM, Kuncan KM. Pediatric emergency department analgesic practice. Pediatr Emerg Care 1997; 13:103-6. 8. McCaffery MM, Wong DL. Nursing interventions for pain control in children. In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents. Baltimore: Williams & Wilkins; 1993.p.295-316. 9. Chambers CT, Reid GJ, McGrath PJ, Finley GA. Development and preliminary validation of a postoperative pain measure for parents. Pain 1996;68:307-13. 10. Terndrup TE, A'gostino J. Pain control, analgesia, and sedation. In: Barkin RM, editor. Pediatric emergency medicine: concepts and clinical practice. Second edition. St. Louis: MosbyYear Book; 1997.p.48-64. 11. American Academy of Pediatrics Committee on Drugs. Alternative routes of drug administration--advantages and disadvantages (subject review). Pediatrics 1997;100:143-52. 12. Wong DL.Whaley and Wong's essentials of pediatric nursing. 5th ed. St. Louis:Mosby;1997.
INTERNATIONAL JOURNAL. OF TRAUMA NURSING/Manley 133
RN,
"This will only hurt for a moment. .... Children tolerate pain much better than adults." "Narcotics are very dangerous drugs for children and cause addiction."
BSN,
CEN
and reliable pain measurement tools are becoming available. New, better therapies that incorporate both nonpharmacologic and pharmacologic are being implemented. This article will review various aspects of pain control for children in acute care settings. BARRIERS
hese comments represent some of the myths that persist regarding the perception and management of pain in children. Pain control is n o w r e c o g n i z e d as a major international health care issue for adults and children, and pain is the number one health care complaint prompting patients to seek medical attention in the United States. 1,2 Although it is recognized that acute pain serves as a warning that tissue damage has occurred, less is known about a person's physiologic and emotional responses to pain. Pain is a critical problem for pediatric trauma patients. Small children have an immature nervous system and may be more susceptible to intense pain. ~ Significant pain experienced early in life can cause lasting emotional and physiologic damage. 2 Acute trauma, burns, and the procedures and testing associated with treatment, produce pain that disrupts metabolic, autonomic, and thermoregulatory function? Immunologic function was influenced negatively in laboratory animals subjected to acute pain and stress. 4 W h e n pain m a n a g e m e n t has b e e n aggressive, children have been noted to recover from surgery faster. 2 The knowledge of pain is still limited; however, over the past decade, pain management has become a distinct medical specialty--with a body of scientific literature that challenges old beliefs. More valid
130 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Manley
PAIN RELIEF
One of the biggest obstacles to adequate pain relief for children is outdated medical information. Pain management is not routinely incorporated into medical, nursing, and allied health care educational curricula in the United States. Many health care settings do not use a standardized method to routinely assess, document, or treat pain. Infants and young children are at a disadvantage because they are unable to verbalize their discomfort. If the nurse is unaware of or misinterprets their discomfort, it might be falsely assumed that the child does not hurt. 5 Certainly, infants are "expected" to cry in unfamiliar surroundings. An unfounded fear of addiction or adverse effects to narcotic drugs is a c o m m o n misunderstanding for treating children in pain. Studies show pain control in children is often neglected, particularly in the emergency department setting. It has been found that analgesics were used less frequently in children than in adults, the children were often given inadequate dosages, 6 there were significant delays in administering analgesics t o injured children, and poor documentation of the child's response. 7 Narcotics are withheld out of fear of producing respiratory depression and hypotension; however, these side effects are largely dose related and often reversible with naloxone. 2,6,7 ASSESSING
Linda Manley is an EMS coordinator at Children's Hospital, Columbus, Ohio. For reprints write Linda Manley, RN, BSN, CEN, Children's Hospital, 700 Children's Dr., Columbus, OH 43205-2696. Int J Trauma Nurs 1997;3:130-3. Copyright © 1997 by the Emergency Nurses Association. 1075-4210/97/$5.00 + 0 6511185252
TO ADEQUATE
PAIN IN CHILDREN
Assessing and measuring pain in infants and children are difficult tasks, particularly in the preverbal age group. Pain is often assessed using a child's self-report, or by observing behavior and physiologic responses and obtaining a parental report about the child's pain. Self-report and Pain Rating Scales. If the child is able to cooperate, self-reporting is considered the
VOLUME 3, NUMBER 4
Table 1. Pain rating scales Tool Numeric scale
Age
Description
School age
Straight line with
the end points identified as
Poker Chip Tool 12 4-8 yr
"no pain" (0) or 'Worst pain" (10). The child chooses 1-4 poker chips, each of which symbolizes a "piece of hurt." One chip is a "little hurt," whereas four
Table 2. Summary of pain management strategies used for children Nonpharmacologic
Pharmacologic
Distraction Relaxation Positive reinforcement Preparation Others: transcutaneous
Nonnarcotic analgesics:
electrical nerve stimulation, visual imagery, hypnosis
More than 4 yr
"most hurt." Seven facial
expressions are provided, each depicting a degree of pain that correlates with the child's pain
experience.
best indicator of pain. ~ A child who states he or she is experiencing pain should be believed. Self-reports of pain work best if the child is 3 years of age or older. Young children may not understand terms such as pain, discomfort, excruciating, or cramping. They may simply describe the pain as "I hurt," "I don't feel good,':' or simply "Ouch." Children should be encouraged to point to where it hurts, because their language for b o d y areas may not correspond with the examiner's. Verbal children can use self-reports of pain to describe their symptoms and to rate the efficacy of treatment. Several pain rating scales are available for use in children (Table 1); however, no single tool will serve the needs of all children. Some scales require a trained observer to reduce interobserver variability and practice, whereas other scales are dependent on the child's verbal and cognitive development. Behavioral Responses. Observing behavioral changes, particularly in the preverbal child, is a valuable pain assessment tool. Certain behavioral responses (e.g., irritability, crying, screaming, lethargy, moaning, brow furrowing) and motor responses (e.g., arched or rigid body, shuddering, involuntary shaking, or tensed extremities) are associated with
OCTOBER-DECEMBER 1997
ibuprofen, ketorolac
Sedatives: diazepam, midazolam Opioid analgesics: morphine sulfate, fentanyl Transdermal: EMLA TAC LET Transmucosal
chips are the Faces Scale 12
acetaminophen,
pain. Loss of appetite and disturbed sleep patterns may also be associated with pain. Physiologic Responses. Acute pain activates the sympathetic nervous system, which produces an increased heart rate, respiratory rate, blood pressure (due to vasoconstriction), diaphoresis, and mydriasis (dilated pupils). If a child's pain is not treated adequately, peripheral arterial vasoconstriction can decrease the amount of oxygen supplied to peripheral tissues, interfere with skin grafts "taking" for children with burns, and delay w o u n d healing. 3 Parental Reports of the Child's Pain. Parents can be a valuable source of information for assessing a child's pain; however, this source is often neglected. Parents k n o w their child and are sensitive to changes or pain cues in the child's behavior. 9 They can identify behaviors that accurately predict the intensity of their child's pain. 8
PAIN MANAGEMENT
STRATEGIES
A combination of therapeutic strategies are available to relieve discomfort in children. Because nurses spend a great deal of time with the child and family, they should be aware of the multiple options that are available for helping children who need relief from pain. The options can be grouped according to nonpharmacologic and pharmacologic approaches (Table 2 ). Nonpharmacologic Approaches. A number of interventions that can be helpful in reducing procedure-related pain and distress are often overlooked in an acute care setting. Distraction is used to focus the patient's attention and place the pain stimuli in the periphery of awareness. Distraction does not actually decrease pain intensity, but it can decrease
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Manley 131
the associated emotional distress. 1 Distraction works well for preschool and older children. Examples of distracting activities include muscle contraction (such as clenching the fis0, screaming before the pain, conversation (especially humorous), and fantasy. 8 Other ideas include reading colorfully illustrated books, singing, listening to music or songs, and blowing b u b b l e s - - a very popular distracting activity. At one time, staff would inflate latex gloves to make a balloon. This practice is discouraged because children have bitten the inflated fingers, causing the glove to suddenly deflate, obstruct the child's airway, and cause death. The additional danger of latex allergy is becoming more of a threat to sensitive individuals and a concern for all practitioners. As with distraction, relaxation does not reduce the intensity of pain, but can reduce the associated distress. Parents should be encouraged to stay with their children during painful procedures to provide verbal encouragement and touch. Rocking chairs are comforting to both the child and parent, Slow, deepbreathing exercises may be helpful for the older child
Parents should be encouraged to stay with their children during painful procedures to provide verbal encouragement and touch. and should be practiced before a painful procedure, if possible. Anticipating a painful event is anxiety provoking to most children. Giving the child and parents procedural information (what will be done) and sensory information (what it may feel like) may decrease this stress, a For example, the child might be told that "the soap to clean your arm will be cold and a brownish color," or the local anesthetic might feel like a "pinch" or a "prick." Painful procedures should be performed in a room separate from the child's living area w h e n possible to provide the child with a "safe" environment. Positive reinforcement is a relatively simple intervention that is frequently overlooked. The child should be encouraged during the entire painful procedure and rewarded for any positive behavior, even if distressed3 Rewards can take the form of stickers, badges, prizes, "certificate of bravery," or frozen ice treats. Children should never be punished or made to feel ashamed because they were unable to cooperate. Other nonpharmacologic techniques that can
132
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Manley
lessen the perception of pain include transcutaneous electrical nerve stimulation, visual imagery, and hypnosis. Pharmacologic Approaches. Although most children are accustomed to the oral route for medications, this should not be considered in trauma. Oral medications are contraindicated in severely injured patients, such as those with a head injury, and even minor trauma can precipitate vomiting. Recent advances in drug formulations and routes of administration have helped to change the options. Nonnarcotic analgesics, such as acetaminophen and ibuprofen, are the most widely prescribed analgesics for children. Acetaminophen possesses analgesic and antipyretic properties, has an onset of action of 30 minutes, and is useful for mild pain. Acetaminophen is administered orally or rectally, at a dose of 15 mg/kg. 9,i° Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is generally more potent than acetaminophen, but carries more risk of gastrointestinal irritation or bleeding and reversible platelet dysfunction with long-term use.a° Ibuprofen is administered orally, at a dose of 10 mg/kg. Ketorolac is another NSAID that is gaining popularity in pediatric care. It is a potent drug with analgesic properties comparable to morphine sulfate. Ketorolac is the only NSAID that can be administered intravenously, intramuscu]arly, and orally. The dose is 0.5 to 1.0 mg/kg?, l° Sedatives decrease activity and anxiety, thereby facilitating better cooperation with procedures, Sedatives do n o t relieve pain and must be used in conjunction with an analgesic if treating pain. Common sedatives used for children include the benzodiazepines diazepam and midazolam. Benzodiazepines have sedative, hypnotic, amnesic, anticonvulsant, and respiratory depressant effects. 5a° Midazolam is a particularly versatile medication because it can be given via several routes. Morphine sulfate (MS) is considered the gold standard for pain medications. MS is a potent narcotic metabolized by the liver that has analgesic, sedative, anxiolytic, and euphoric effects. 1° MS is indicated for moderate-to-severe pain. It should be used cautiously in neonates because this age group is particularly susceptible to respiratory depression, and the half-life of the drug is prolonged, a° Complications associated with MS are often dose related and include hypotension (as a result of histamine release and vasodilatation), respiratory depression, decreased gut motility, constipation, urinary retention, and biliary spasm. 1° Therapeutic doses only
VOLUME 3, NUMBER 4
rarely result in complications and can be easily reversed with naloxone. Fentanyl is an extremely potent, rapid-acting synthetic narcotic, 100 times as potent as MS. It is rapidly gaining popularity for controlling severe pain in children. 5,1° When given intravenously, fentanyl has a rapid onset of action--3 to 5 minutes, but a relatively short duration of action--30 to 40 minutes, making it an ideal drug for procedural pain. 5 The recommended dose is usually 2 to 3 t.tg/kg given over 3 to 5 minutes intravenously. Fentanyl can result in respiratory depression, apnea, and bradycardia, therefore, the child should be carefully monitored. 5,1° The transdermal and transmucosal routes of drug administration offer distinct advantages for children. These methods are relatively painless and do not require intravenous access. Several medications, including sedatives and narcotics, can be administered via the transdermal and transmucosal routes. Transdermal administration may be particularly effective for children because their skin is thinner and has a relatively rich blood supply, n Neonates
Ketorolac is another NSAID that is gaining popularity in pediatric care. It is a potent drug with analgesic properties comparable to morphine sulfate. have extremely thin skin; therefore, transdermal drugs must be used with greater caution to avoid toxic levels. Examples of common transdermal medications include eutectic mixture of local anesthetics (EMLA), used to reduce procedural pain (e.g., intravenous access, lumbar puncture), and tetracaine, adrenaline, and c o c a i n e p r e p a r a t i o n (TAC); or lidocaine, epinephrine, tetracaine (LET), often used for pain control and hemostasis during laceration repair. Optimal pain control with EMLA and TAC/ LET requires 60 and 30 minutes, respectively. Special care must be taken to avoid contact with mucous membranes and application to areas with limited collateral circulation. The cocaine preparations should be used with particular caution because cocaine toxicity and death can occur if improperly administered. 5 Transmucosal administration is very effective because mucosal surfaces are rich in blood supply and provide for rapid transport of the drug into the
OCTOBER-DECEMBER 1997
systemic circulation. This route avoids degradation of the drug by first-pass hepatic metabolism. 11 Transmucosal sites include the respiratory tract, nasal cavity, sublingual buccal membranes, and rectum. Drug absorption for each route is dependent on the volume and concentration of the drug, contact time, venous drainage of the particular mucosal tissue, and the drug pharmacokinetics.
SUMMARY The assessment and management of pain in children has been essentially ignored until recently. Thankfully, these "dark ages of pain" are ending. The trauma nurse is an integral part of the pain management team and can have a positive impact on outcome by using a combination of relatively simple strategies. These include using multiple types of assessment to measure the severity of pain; providing adequate pain relief with a combination of pharmacologic and nonpharmacologic interventions; and carefully monitoring and documenting the efficacy of all pain management approaches. REFERENCES 1. Anderson CTM, Zeltzer LK, Fanurik D. Procedural pain. In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents. Baltimore: Williams & Wilkins; 1993.p.435-8. 2. Schrof JM. Easing hurt in small bodies. US News & World Report 1997;(March):60-2. 3. Carr, Osgood, Szyfelbein. Treatment of pain in acutely burned children. In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents. Baltimore: Williams & Wilkins; 1993.p.495-504. 4. Leibeskind JC. Pain c a n kill. Pain 1991 ;44:3-4. 5. Selbst SM, Henretig FM. The treatment of pain in the emergency department. Pediatr Clin North Am 1989;36:965-78. 6. Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: patterns of analgesic utilization. Pediatrics 1997;99:711-4. 7. Friedland LR, Pancioli AM, Kuncan KM. Pediatric emergency department analgesic practice. Pediatr Emerg Care 1997; 13:103-6. 8. McCaffery MM, Wong DL. Nursing interventions for pain control in children. In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents. Baltimore: Williams & Wilkins; 1993.p.295-316. 9. Chambers CT, Reid GJ, McGrath PJ, Finley GA. Development and preliminary validation of a postoperative pain measure for parents. Pain 1996;68:307-13. 10. Terndrup TE, A'gostino J. Pain control, analgesia, and sedation. In: Barkin RM, editor. Pediatric emergency medicine: concepts and clinical practice. Second edition. St. Louis: MosbyYear Book; 1997.p.48-64. 11. American Academy of Pediatrics Committee on Drugs. Alternative routes of drug administration--advantages and disadvantages (subject review). Pediatrics 1997;100:143-52. 12. Wong DL.Whaley and Wong's essentials of pediatric nursing. 5th ed. St. Louis:Mosby;1997.
INTERNATIONAL JOURNAL. OF TRAUMA NURSING/Manley 133