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Management of Pain in Pediatric Trauma Patients

Management of Pain in Pediatric Trauma Patients    

 

Please note that at any point in this algorithm, a consult to the pediatric pain team can be performed and should be considered when initiating pharmacologic therapy  

 

  1. 1. Provide education about expectations regarding pain.  Below are some important talking points to include. 

  • We have a team that works to manage your/your child’s discomfort/pain.   
  • We will use a combination of medication and other techniques to control your/your child’s pain. 
  • We will do our best to keep you as comfortable as is safe.   We may not be able to take the pain away completely.  The goal is to get your pain to a level that you can get to physical therapy and get ready to go home.    
  • For you/your child’s safety, the doses of the medications we give are based on each child’s weight and we will monitor you/your child closely.   
  • There are different types of pain.  Based on type of pain you feel, there are different strategies and medications we can use.  
  • There are other factors that can affect pain perception, such as anxiety and insomnia, and we will assess for these factors and address any of them that may be present.   

 

  1. 2. Perform initial assessment of pain 

  • Severity: FLACC Scale, Numeric Pain Scale or Wong-Baker  Faces Pain Scale as per patient age  
  • Quality of pain 
    • Sharp/cramping/neuropathic
    • Focal/diffuse 

 

  1. 3. Perform initial assessment other factors contributing to perceived pain 

  • Anxiety- PROMIS short form (addendum) 
  • Depression- PROMIS short form (addendum)  
  • Insomnia – discuss with patient, family, RN how the patient is sleeping 
  • Comorbid conditions/diagnoses 
  • Delerium - >5yo: psCAM-ICU; >5yo: pCAM-ICU 
  • Withdrawal – evaluate patient’s prior medication history – before and during hospitalization 

 

  1. 4. Address any of these other factors that have been identified as a problem 

  • If anxiety/post-traumatic stress identified as an issue- 
    • child life can be consulted by RN without physician approval
    • Psychiatry or psychology consult should be initiated by physician as felt is indicated 
    • non-pharmacologic therapies (music/art therapy) can be consulted by RN without physician approval 
    • typically defer to psychiatry for pharmacologic therapies  
  • If insomnia identified as an issue -  
    • Work on day/night cues   
      • Child life can help greatly with this 
    • Sleep hygiene  
      • Minimizing daytime naps, particularly naps in the evening 
      • Turn off television/lights at night 
      • Consider minimization of vital sign assessment at night if appropriate (should be discussed with physician team) 
      • Consider pharmacologic therapy  
      • Melatonin – 0.05mg/kg (max at 9mg total)  
      • >2yo: Diphenhydramine 0.5mg/kg/dose QHS PRN sleep (maximum 50mg/dose)  
  • Delirium management if present   

 

  1. 5. To address pain, start with non-pharmacologic therapy 

  • Child Life consult  (RN can consult without attending approval) 
  • Consider the following:  (RN can consult without attending approval) 
    • Music therapy   
    • Art therapy  
    • Aromatherapy   
    • Massage therapy   
    • Pet therapy   
  • For localized pain, consider temperature therapy (heat/cold)  
  • If fracture, assess for need for splinting/repositioning  

 

  1. 6. Within 30 minutes of initial assessment, should reassess pain. 

  • Ensure prior therapies are being properly utilized. 
  •  If need pharmacologic therapy, chose starting regimen.   
    • Scheduled Acetaminophen and NSAIDs are typically first line, unless contraindicated (See chart at bottom) 
      • Acetaminophen  
        • PO:  10-15mg/kg/dose Q4-6hH (maximum 75mg/kg/day or 4 grams)   
        • PR:  20-25 mg/kg/dose Q6H   
        • IV:  7.5-15mg/kg/dose Q6H maximum 1000mg/dose   
    • Ibuprofen   
      • PO: 10mg/kg/dose Q6-8H maximum 600mg/dose   
    • Ketorolac  
      • IV/IM: 0.5mg/kg/dose Q6H maximum 30mg/dose   
      • PO: 1mg/kg/dose Q6Hmaximum 10mg/dose   

 

  1. 7. Within 60 minutes of administration of pharmacologic therapy, should reassess pain  

  • If acetaminophen and NAIDS are not scheduled, make them scheduled.     
  • Ensure proper utilization of prior therapies   
  • If additional therapy needed, consider consult to Pediatric Pain Service and proceed with symptom-driven therapies   
  • Cramping Pain or patients with high tone (ie- cerebral palsy):  Muscle Relaxants  
    • Diazepam  
      • PO:  0.1mg/kg/dose Q6H   
      • IV:  0.05 mg/kg/dose Q4-6H maximum 10mg/dose   
    • Methocarbamol   
      • PO/IV:  15mg/kg/dose Q8H 
    • Cyclobenzaprine  
      • Safety of extended-release not established in those <18yr   
      • Immediate Release   
        • >15yo: immediate release 5mg PO Q8H, may increase to 7.5-10mg Q8H PRN maximum 30mg/day   
        • <15yo:  safety not established   
  • Neuropathic pain   
    • Gabapentin   
      • 3-12yo:  PO:  5-15 mg/kg/day divided Q8H   
      • >12yo:  PO:   300mg Q8  (Can increase to 600mg Q8H if needed)   
  • Localized Pain   
    • Lidocaine Patch   
      • >12yo: 1 patch Q24H   
      • <12yo: consult pain team for partial patch dosing   
    • Consult Pediatric Pain Service for evaluation for regional anesthesia 

      • Place “Inpatient consult to peds pain management” order in EPIC which automatically pages ANS Acute Pain RN 
      • Thoracic and abdominal trauma: epidural and Erector Spinae Plane blocks are comparably effective and provide superior analgesia compared to systemic opioids   
      • Regional UE and LE blocks are not contraindicated but can potentially mask compartment syndrome, consult with orthopedics prior to initiating   
      • Regional block preferred for amputation to avoid phantom pain 
      • US-guided fascial plane blocks can be given as single injections or infusions   
        • Serratus anterior (T2-9)- chest wall trauma   
        • Transversus abdominis (T7-L1)– abdominal incisions or abdominal wall pain   
        • Quadratus lumborum (T7-L1) - Abdominal, pelvic, iliac crest, liver, kidney and bladder pain   
        • Erector Spinae blocks- (T2-L3) – anterior and posterior chest wall trauma    

 

  1. 8. Reassessment of pain and other factors that can affect perceived pain.    If pain remains poorly controlled, consider the following.  

  • Ensure proper utilization of prior therapies.     
  • If additional therapy needed, consider opioids.  
    • Oxycodone   
      • PO:   in opioid naïve patients 0.1mg/kg Q4-6H. Can increase up to 0.2mg/kg/dose 
    • Morphine   
      • PO:  0.2 mg/kg/dose Q3-4H (can increase up to 0.5mg/kg/dose)   
      • IV:  0.05-0.2 mg/kg/dose Q2-6H   
      • Opioid naïve maximum doses based on age:   
        • Infant: 2mg/dose   
        • 1-6yo: 4mg/dose   
        • >6yo: 8mg/dose   
    • Hydromorphone   
      • PO: 0.03mg/kg Q4H (can increase up to 0.06mg/kg/dose)   
      • IV:  0.015mg/kg/dose Q4-6H   
    • Fentanyl *requires NICU, CICU, or PICU status   
      • IV:  1-2 mcg/kg/dose Q1 H   

 

  1. 9. Reassessment of pain and other factors that can affect perceived pain.    If pain remains poorly controlled, consider the following.   

  • Ensure proper utilization of prior therapies   
  • If pain persists, consider ketamine:   
    • IV: Policy A14-175 (PICU, PCICU, ED, Sedation, 4N)   
      • IVP: 0.1-0.4mg/kg (maximum 35mg/dose)   
      • IVPB: 0.1-0.4mg/kg over 15minutes (maximum 35mg/dose)   
      • Continuous infusion requires PCA order per pain team     
    • PO: Policy PH08.01.065   
      • PO: 0.25-1mg/kg/dose every 6 to 8 hours (maximum 5mg/kg/day)  
    • Use ideal body weight for obese patients    

 

  1. 10. At any time can consider psychology consult   

  • Persistent, intense distress interfering with medical care and quality of life.   
  • You are concerned about the patient’s safety.    
  • Psychological disorder, known or suspected history of a psychological disorder (e.g. ADHD, anxiety, depression).   
  • Developmental disorder (e.g. Down Syndrome, autism) that interferes with medical care and quality of life.   
  • General team consultation about ways to work with patient and family to maximize care.   



Disclaimer

These guidelines are not intended as a directive or to present a definitive statement of the applicable standard of patient care.  They are offered as an approach for quality assurance and risk management and are subject to (1) revision as warranted by the continuing evaluation of technology and practice; (2) the overall individual professional discretion and judgment of the treating provider in a given patient circumstance; and (3) the patient’s willingness to follow the recommended treatment. 


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