Pain is under-treated in all patients but more so in pediatric patients because providers are nervous about calculations and dosing. Children are often unable to communicate their pain. Knowing your EMS guidelines and protocols, if you were lying at the scene of an accident in horrific pain, would you allow the responders to skip the med pains because they don't want to do the math? Would you let them skip it if your child were in pain?

Addressing pain in the field should be one of your biggest priorities after life saving measures. Many studies have shown that the emotional damage, the pain, and anxiety of an injury can have long-lasting effects on the patient. Treating pain can lessen the emotional trauma our children experience.

Knowing your options and using them is the first step. Morphine is falling out of fashion as it has a slow (25 min) onset. Fentanyl takes around 10 minutes to peak and has an internasal route option as well as IV. It allows EMS in the field to treat pain quickly.

Pediatric Pain Management: Aiming for an “Ouchless” Experience

Background

No medical provider wants to see a child suffer. Caring for a child in pain can be stressful for all involved including providers, parents, and the children themselves. Unfortunately, studies show that administration of appropriate analgesia in children lags behind that provided to adults in similar situations. The reason for inadequate pain management in pediatric patients is multifactorial and there are many barriers to success, both in emergency departments and in the prehospital setting. These barriers include difficulty assessing pain in young patients, fear of medication adverse effects, unfamiliarity with new products or techniques, staffing limitations, and situational constraints. Despite barriers, pain control in the pediatric patient is immensely important. Recent data suggests that inadequate pain control in pediatric patients can affect their long term emotional well-being. Additionally, inadequate pain control in the pediatric patient can alter their response and perception of future painful experiences. For these reasons, pain control is not only important to alleviate the immediate suffering of a child, but also important for their future and overall well-being.

Assessing Pain in a Pediatric Patient

One major barrier to adequate pain control in children is difficulty in assessing level of pain. This can be particularly difficult in children who are not verbal. Pain assessment scales can be used to help assess pediatric pain. For children younger than four years of age, the National Association of EMS Physicians (NAEMSP) recommends the Faces, Arms, Legs, Cry, Consolability (FLACC) scale or Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS). For older children, NAEMSP recommends a self-report scale such as the Wong Baker Faces scale (pictured).

Non pharmacologic pain management

There is an obvious connection between anxiety and pain. Particularly for children, the anxiety of a stressful situation can lead to worsened pain. There is an important non-pharmacologic component of pain management in the pediatric patient. Examples of techniques you can use to aid in success of pediatric pain management are below:

1. Distraction techniques

• Have age appropriate conversations with the child. You can ask questions like “What did you do in school today?” and “What do you like to do for fun?”

• Music and cell phones can work well for distraction

• Consider creating a “toolbox” of distraction tools or supplies with simple toys such as pinwheels or bubbles

• Pacifier or sucrose pacifiers for infants

2. Sensory interventions

• Using comfort position when possible

• Splinting or traction can help alleviate pain when indicated

• Cold or hot packs

• Swaddling and pacifiers for infants

Additionally, engagement of parents and caregivers is paramount to success of children's pain management. Parents can often provide children with a source of comfort and can help minimize distress in a stressful situation. Involving them in their child’s care can both alleviate stress for the parent, child, and ultimately you as the medical provider. Also of note, parents can be particularly helpful resources for children with underlying medical problems such as developmental delay, mental health concerns, and autism spectrum disorder. Caregivers of children with these issues often know how best to communicate with their child and also know how to communicate their child's needs to you as a provider.

Pharmacologic Pain Management

There are many different options for pharmacologic pain management in pediatric patients. As a general rule, NSAIDs and Tylenol are great choices of first line analgesia in children. These medications work best for mild to moderate pain, and can be used as adjunct medications for severe pain. Also for severe pain, opiates should be considered. Don’t forget to consider intranasal (IN) or intramuscular (IM) route of administration for medications for pediatric patients when IV access is difficult or not available. Medications used frequently for pediatric pain management are outlined below:

1. NSAIDS (ibuprofen) and Tylenol (acetaminophen)

• Indication: mild to moderate pain

• Dose and route: ibuprofen 10 mg/kg PO; acetaminophen 15 mg/kg PO or PR

• Remember: no NSAIDs in infants younger than 6 months of age

2. Opiates

• Indication: severe pain

• Dose and route: fentanyl 1 mcg/kg IV or 2 mcg/kg IN; morphine 0.1 mg/kg IV

• Caution: should not be used in patients with a GCS <15

• Reassess respiratory status frequently; use naloxone if necessary for respiratory depression

3. Ketamine

• Indication: severe pain

• Dose and route: 0.1-0.3 mg/kg IV; 0.5-1 mg/kg IM or IN

• Remember: dosing for pain control with ketamine is sub-dissociative and lower than sedating dosing of ketamine

Handtevy and Broselow

We all know that pediatric patients, especially critically ill patients, can cause anxiety among medical providers of all backgrounds. We also know that part of this anxiety comes from weight-based dosing needed for pediatric care. A major cause of medical errors involves under and overdosing of medications, in part because of weight-based dosing and the math required to calculate pediatric doses. One of the first steps in the care of any critically ill child involves obtaining an estimated weight IN KILOGRAMS (we should never be recording pediatric weights in pounds; that only adds to medical error).

Several tools have been developed to help medical providers estimate patient weight. For years, Utah EMS providers have largely used the Broselow tape. The original Broselow tape was introduced in 1986 by Drs. Jim Broselow and Robert Luten. This system uses a length-based estimation for weight in kilograms for pediatric patients, placing them into color-coded categories. The tape also includes medication dosing information for critical drugs based on the color category, and recommended equipment size for critical care equipment according to patient length.

Recently, there has been increased interest in a newer weight estimation system, the Handtevy system, developed by Dr. Peter Antevy. The Handtevy system describes itself as based on both patient age AND length, although most initial decisions are based on patient age because providers usually have that information sooner. Studies show that age-based weight estimation is statistically equivalent to length-based weight estimation. Part of the goal of the Handtevy system is to allow providers to start drawing up medications and preparing equipment before the patient arrives at the ED, so the time to interventions can be shortened. The provider can use the age to estimate patient weight in kilograms, and, because we usually have information about patient age prior to patient contact, we can start to prepare before arriving at the patient’s side.

The Handtevy Method is based on associating five pediatric ages with their corresponding weights in kilograms via a finger counting method on your hand. To obtain the corresponding weight for each age, assign each finger a chronological odd number starting with 1: 1, 3, 5, 7, 9. Each finger represents an age in years. Then, using the same fingers, count up in 5s starting with 10: 10, 15, 20, 25 and 30 to obtain the corresponding ideal body weight in kilograms. For example, a 1-year-old ideally weighs 10 kg, a 3-year-old 15 kg, etc. For the even numbers, use round numbers between odd number’s estimated weights to predict weight. For example, a 2 year-old’s ideal weight is 12 kg (round number between 1 and 3 year old weights, 10 and 15 kg respectively).

There is also a length-based tape associated with the system, although unlike the Broselow tape, the Handtevy tape does not include medication or equipment information. The Handtevy tape goes up to a length corresponding to a weight of 60 kg, and Broselow goes to 40 kg. The Handtevy tape is supposed to be used to estimate weight by length in patients where age isn’t known, or the patient appears larger or smaller than their stated age. With Handtevy, medication and equipment information can be found on printed guides or electronically with a mobile app. The system is also designed to allow for easy memorization of several medications according to weight. However, the color-coded categories are the same as Broselow, allowing providers using different systems to communicate with each other.1

There are very few studies comparing the two systems. One study found that the Broselow tape performed better overall than the Handtevy tape and more closely approximated actual weight, although both tapes tended to underestimate patient weight.2 Another study compared dosing error and time to medication administration for epi and dextrose in a simulation environment (not actual patient care). The researchers found that with dextrose administration, there were more dosing errors and longer times to give the medicine with Broselow, but there were no differences in errors or time to administer epi between the two systems. Both systems were noted to have procedural errors.3

Both systems usually do well in providing medical personnel a fairly adequate and rapid kilogram weight estimation for pediatric patients. Both systems have some advantages and disadvantages. To help prevent medication errors in kids, remember the following:

1. Chose whichever weight estimation system you feel works best for your agency.

2. Train on that system often as skills require repeat training to create comfort and ease of use.

3. Both systems have tapes designed to measure from the top of the head to the heels, not toes, and have a big red arrow showing which side of the tape goes to the head.

4. Practice drawing up medication doses and choosing pediatric equipment with whichever system you chose to use as often as possible. (Again, we can only do things well when those skills are frequently practiced.)

5. Both systems can run into problems when a child is much bigger or much smaller than the average weight/length for age. Both systems emphasize that for most drugs we use, medication dosing is based on “ideal” body weight, and the average weight for length/age is still pretty accurate for dosing, especially for significantly overweight children. Both systems allow providers to go up or down to a different weight category for children who are very much larger or smaller than average.

6. Equipment size, such as endotracheal tubes, are best based on length. This is because regardless of a child’s weight, or if a child is skinny or overweight, the airway is about the same size for each length.

7. Medication errors can occur at several steps along the way. Make sure you use good closed-loop communication with your team to decide:

• What drug to use according to the clinical situation and your protocols
• What dose and/or volume to draw up
• Double check dose and volume before administering it to the patient

References:

1. https://www.jems.com/articles/print/volume-38/issue-8/features/handtevy-method-helps-providers-rapidly.html

2. The Broselow and Handtevy Resuscitation Tapes: A Comparison of the Performance of Pediatric Weight Prediction. Lowe CG, Campwala RT, Ziv N, Wang VJ. Prehosp Disaster Med. 2016 Aug;31(4):364-75. doi: 10.1017/S1049023X16000455. Epub 2016 May 25.

3. Comparison of Errors Using Two Length-Based Tape Systems for Prehospital Care in Children. Rappaport LD, Brou L, Givens T, Mandt M, Balakas A, Roswell K, Kotas J, Adelgais KM. Prehosp Emerg Care. 2016 Jul-Aug;20(4):508-17. doi: 10.3109/10903127.2015.1128027. Epub 2016 Feb 2.

Pain can be a source of both fear and discomfort for children. Effective pain control can improve both the experience for the child and make it easier care for them. One of the best ways to manage pain is non-pharmacological. Never discount the effectiveness of a movie/game on a smart phone or tablet to distract attention away from the injury. Toys are also a great distraction!

Intranasal medication is a very effective way to avoid PIV sticks but remember no more than 2 mL total (1 mL per nostril). For pain control, fentanyl 2 mcg/kg intranasal x 1 (using 50mcg/ml, max 100mcg) is a great option. It has an onset of action of 5-10 minutes, per EMS protocol. If you have an IV in place, fentanyl 1 mcg/kg (max 50 mcg per dose) IV/IM/IO, or morphine 0.1 mg/kg IV/IM/IO (max 4mg) per EMS protocols are a great option for pain. One medication that especially shines with obvious long bone injury is diazepam (valium). It acts as a muscle relaxer to relax the spasms that are causing the patient a high level of pain that the fentanyl and morphine are not treating. Dosing of diazepam is 0.1 mg/kg (max 5mg), may repeat once in 10 minutes if needed (max total= 10mg). IM administration is not preferred unless there is no other option. If needed use diazepam 0.2mg/kg IM once - per EMS protocols.

EMSC Pediatric Education for Prehospital Providers

Register online at peppsite.org. Look up classes in Utah and find the one that will work for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at eandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth