1
Pediatric Pain Management in the
Emergency Setting
SECOND EDITION 2013
EMSC 2013
Illinois Emergency Medical Services for Children is a collaborative program between
the Illinois Department of Public Health and Loyola University Health System
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Hyperlinks
Throughout this module hyperlinks to
resources are underlined and in a different
color font.
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Illinois EMSC
 Illinois Emergency Medical Services for Children (EMSC) is a collaborative
program between the Illinois Department of Public Health and Loyola
University Health System, aimed at improving pediatric emergency care
within our state.
 Since 1994, the Illinois EMSC Advisory Board and several committees,
organizations and individuals within EMS and pediatric communities have
worked to enhance and integrate:




Pediatric education
Practice standards
Injury prevention
Data initiatives
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Illinois EMSC
The goal of Illinois EMSC is to ensure that appropriate
emergency medical care is available for ill and injured
children at every point along the continuum of care.
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Disclaimer
• Illinois EMSC has worked to ensure that all information presented is
accurate and congruent with current practice as of the date of publication.
Please note, the information does not serve as a substitute for existing
policies and procedures. These guidelines may be modified at the discretion
of the healthcare provider.
• This educational activity’s planners have indicated they have no bias or
conflict of interest.
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Citation
An electronic version of this document is available on the Illinois EMSC
Web site: www.luhs.org/emsc
• All training materials are considered under public domain, and can be
utilized to conduct similar educational programs provided there is
appropriate acknowledgement of the source of these materials.
• Suggested Citation: Pediatric Pain Management in the Emergency Setting,
Illinois Emergency Medical Services for Children, 2013.
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Acknowledgements
• Pediatric Pain Module Revision Workgroup
Ellen Goldsworthy RN, APN, CEN
Clinical Nurse Specialist, Emergency Services
Swedish American Hospital, Rockford, Illinois
Christine Kennelly RN, MS, CCRN
Educator, Illinois EMSC
Maywood, Illinois
Michele Habich DNP, APN/CNS, CPN
Pediatric Clinical Nurse Specialist,
Central DuPage Hospital, Winfield, Illinois
Kirk Schubert PharmD
Emergency Medicine
Swedish American Hospital, Rockford, Illinois
Gina Hardy RN
Nurse Manager
Bright Star, Elmwood Park, Illinois
• Illinois EMSC Advisory Board
• Illinois EMSC Facility Recognition Committee
• Illinois EMSC Quality Improvement Subcommittee
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Exclusion
• Pediatric procedural sedation and analgesia (PSA) is
not within the scope of this module.
• PSA references are provided at the conclusion of this
module in Appendix A.
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Objectives
At the conclusion of this module, the learner will be
able to:
1. Discuss current pediatric pain management
2. Improve application of evidence-based
pediatric pain management interventions
3. Dispel common myths
4. Support development of pediatric pain policies and
protocols
5. Facilitate quality improvement in the pediatric pain
process
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Table of Contents
• Introduction
• Pediatric Pain Physiology
• Pediatric Pain Management
▫ Pediatric Pain Assessment
▫ Teamwork in Pain Management
▫ Interventions
 Non-pharmacologic Interventions
 Pharmacologic Interventions
• Pediatric Pain Quality Monitoring
• Appendices
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Children and emergency care
• Of the almost 129 million visits to the
ED in 2009, children 0-17 years
accounted for 28 million or 22% of
visits.1
22%
• Pain management is a significant
challenge in Emergency Medical
Services (EMS) and Emergency
Department (ED) care settings.
• Research shows continued under
treatment in pre-hospital and ED
settings.2-7
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Recognize painful pediatric
presentations
Used with permission from Illinois EMSC
Used with permission from Illinois EMSC
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Anticipate painful pediatric events
Blood draw
Immunization or vaccination
IV start
Laceration repair
Lumbar puncture
Fracture reduction
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Which regulatory agencies guide pain
management?
Food and Drug
Administration
(FDA)
State Board of
Health
Drug Enforcement
Administration
(DEA)
State Professional
Regulation Boards
for Medicine,
Nursing, and
Pharmacy
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What other organizations guide pain
management?
• Global Health Authorities
▫ World Health Organization (WHO)
• Accreditation and Certifying Organizations
▫ Det Norske Veritas Healthcare Inc. (DNV)
▫ Healthcare Facilities Accreditation Program (HFAP)
▫ The Joint Commission (TJC)
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Which professional organizations
guide pain management?
American Society
for Pain
Management in
Nursing
American
Medical
Association
Emergency Nurses
Association
(ENA)
(ASPMN)
(IASP)
(AMA)
National
Association of
Emergency
Medical System
Physicians
(NAEMSP)
American
Academy of
Pediatrics
(AAP)
American
College of
Emergency
Physicians
(ACEP)
International
Association for
the Study of Pain
Pain
management
National
Association of
Emergency
Medical
Technicians
(NAEMT)
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Guidance from AAP, ACEP, ENA
NAEMPS and NAEMT and others8
• Guidelines for the Care of Children in the Emergency
Department states that EDs serving children should have
among other things:
▫ Policies, procedures and protocols that include patient assessment,
reassessment and documentation
▫ Pediatric pain competencies related to assessment and treatment
▫ Pain scale and assessment tools appropriate for age
▫ Quality Improvement/Performance Improvement (QI/PI) plan that
includes




Pediatric-specific indicators
The collection and analysis of the data to discover variances
A process for improvement based on the data
A process for evaluating the success of this plan
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Principles to
optimize pain
management
Evaluate using
assessment
and self report
Recognize
that children
are at high risk
for inadequate
pain
management
Guide
management
with evidence
based
assessment
and treatment
Develop
analgesic
protocols using
multidisciplinary teams
Support pain
management
with clinical
resources and
education
Offer both nonpharmacologic
and
pharmacologic
interventions
Initiate
analgesia early;
even in the
absence of a
diagnosis
Provide
individualized
discharge
instruction
This triangle contains summarized
selections from Optimizing the
Treatment of Pain in Patients with
Acute Presentations9 of the core
principles promoted by ASPMN,
ENA, ACEP and APS.
Consider
referral to case
manager, pain
team or center
for palliative
care
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Summary
• Children comprise a significant proportion of the ED
population, and frequently present with pain
• Many organizations offer guidelines to improve pain
management in the emergency setting
• Illinois EMSC is providing this module to improve
pain management in the emergency setting
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Four pain myths
1. Babies can’t feel pain
2. Children don’t remember
pain
3. Children can’t have chronic
pain
4. Getting used to pain is part
of growing up
It’s time to give up the
fairy tales
Used with permission from Microsoft
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Anatomic components related to pain
transmission10,11
•
•
•
•
•
•
•
•
•
Chemical mediators
Nociceptors
A delta fibers
C fibers
Dorsal horn of the spinal cord
Thalamus
Limbic system
Cerebral cortex
Endorphins
All components are
present by 24 weeks
gestation12
Illinois EMSC 2013
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24
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Newborn pain physiology review
• Newborns :
• have functional peripheral and
central nervous system
structures at birth
• perceive pain whether
premature or full-term
• lack descending inhibitory
neurotransmitters until about 3
months of age 12
• feel pain more intensely until
those transmitters develop13
Used with permission from Microsoft
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Pain has metabolic effects
• Increased release of
▫ Catecholamines
▫ Glucagon
▫ Corticosteroids
• The catabolic state induced by acute pain may be more damaging to infants and
young children due to their higher metabolic rates and lower nutritional reserves
than adults10
• Increased morbidity and mortality was demonstrated in infants having surgical
procedures when pain was not controlled 14
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Why are there differences between
pain in individuals?12
• The pain experience does not
reflect a simple one-to-one
relationship between tissue
damage and pain
• Pain is a personal experience
• If pain were hardwired, each
noxious stimulus would elicit the
same response and same
intensity every time in every
person
Subsequent
pain
interventions
Physical
factors
Previous pain
experiences
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Creation of a pain memory15,16
Recurrent
pain17-21
Undertreated
pain
Developmental
factors
Past experience
Temperament
Pain
memory
Coping
Developmental age
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Increased
fear of
medical
procedures
Restricted
social and
athletic
activities from
chronic pain22
Higher pain
ratings than
others with a
similar
condition
Behavioral
Effects
Missed
school days
from chronic
pain22
More anxious
infant, toddler
and
preschooler
Recounting
of pain
nightmares
Behavioral
effects of pain
memories16
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Summary
• Pain perception is a neurologic phenomena
• Infants have nervous system components present
and functioning at birth; inhibitory
neurotransmitters mature at about 3 months
• Repeated pain experiences can have long term
consequences on the child
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Elements of pain assessment23
Assess
physiologic
parameters
Perform
behavioral
observation
Question the
child
Use
standardized
assessment
tool
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Assess physiologic parameters
• Heart rate, blood pressure, respirations
• Perform a focused physical exam
• Children with acute pain
may have:15,24
Consider pain as
the 5th vital sign.19






Tachycardia
Tachypnea
Hypertension
Oxygen desaturation
Dilated pupils
Flushing, pallor
• Children with chronic pain
may not have
altered vital signs
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Elements of pain assessment
Assess
physiologic
parameters
Perform
behavioral
observation
Question the
child
Use
standardized
assessment
tool
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Perform behavioral observation:
Myth: All
13,24,25
infant
babies cry at
their health
care visit
Facial Expression
•
Bulged brow
•
Tightly shut eyes
•
Nasolabial furrow,
•
Stretched mouth
•
Taut tongue10
Note:
• Facial expression
• Extremity activity and tone
• Guarding, splinting
• Position and tone
• Irritability, crying
• Poor feeding
• Poor sleep quality
Used with permission from Microsoft
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Perform behavioral observation:
toddler26
Myth:
Don’t worry,
he always
cries
Used with permission from Microsoft
Note:
• Anger
• Tantrums, regression
• Facial expression
• Extremity activity and tone
• Guarding, splinting
• Position of comfort
• Irritability, crying
• Poor eating and sleep quality
• Restless or unusually quiet
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Perform behavioral observation:
preschooler10,26
Used with permission from Illinois EMSC
Myth:
Pain builds
character
Note:
• Stalling/delaying
• Magical thinking explanations
• Behavioral regression
• Facial expression, grimacing
• Extremity activity and tone
• Guarding, splinting
• Position of comfort
• Irritability, anxiety
• Change in appetite or sleep
quality
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Perform behavioral observation:
school-ager and adolescent10
Note:
• Stalling/delaying
• Flat affect
• Facial expression
• Extremity activity and tone
• Guarding, splinting
• Position of comfort
• Irritability, anxiety
• Change in appetite or sleep
quality
Used with permission from Illinois EMSC
Myth:
Children
who are
playing,
can’t be in
much pain
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Perform behavioral observation:
special needs child
Used with permission from Microsoft
Note:
• Facial expression, grimacing
• Extremity activity and muscle
tone
• Guarding, splinting
• Position of comfort
• Irritability, anxiety
• Behavioral regression
• Change in appetite or sleep
quality
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Elements of pain assessment
Assess
physiologic
parameters
Perform
behavioral
observation
Question the
child
Use
standardized
assessment
tool
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Question the child about pain8,23
Consider:
• The child’s primary language
• Words, or phrases suggested by
the parent/caregiver
• The child’s developmental level
Best practice: Adapt the interview
questions to obtain a complete
pain history.
Explore:
• Location
• Duration
• Quality of pain
• Precipitating factors
• Effect on daily activities
• Pain relief measures
• Previous pain experiences
Best practice:
Self–report of pain is the most
accurate.
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Question the toddler and
pre-schooler10,13,26,27
• Ask the parent/caregiver what the child’s words for pain are
• Using the child’s words for pain, ask:
•
•
•
•
Where it hurts
What it feels like
The child to point directly to where it hurts
If the child is unable to respond, ask the parent/caregiver to
interview the child
Best practice: Avoid comments
that lead a child to believe that
denying pain is a preferred
behavior.
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Question the school age and
adolescent child:10
•
•
•
•
•
•
•
Do you have pain?
Where is the pain?
How long have you had it?
Describe what kind of pain it is
Has it changed?
What makes it better or worse?
How does the pain impact your
daily life?
• Have you had pain in the past?
Used with permission from Illinois EMSC
Best Practice:
Interview an adolescent in private,
away from parent or peer. 28
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Questioning the special
needs child29
• Adapt the questioning and
communication to the child’s
ability to understand and
respond
• Ask the parent/caregiver to
describe:
• The child’s cognitive level and
communication abilities
• Pain-related behaviors
• Effective calming and soothing
measures
Remember, questions should
explore pain:
•
•
•
•
•
•
•
Location
Duration
Quality
Precipitating factors
Effect on daily activities
Relief measures
Previous pain experiences
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Why might children not disclose that
they’re in pain?10,15
• Hoping to avoid painful
treatment
• Fear of being sick
• Fear of healthcare professionals
• Protecting their
parents/caregiver
• Avoiding hospitalization
• Wanting to return to desired
activities
▫ Sports
▫ Social events
▫ School
Used with permission from Illinois EMSC
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Elements of pain assessment
Assess
physiologic
parameters
Perform
behavioral
observation
Question the
child
Use
standardized
assessment
tool
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Choosing a standardized assessment
tool
• Choose an appropriate tool based on the:
▫
▫
▫
▫
Child’s age
Cognitive ability and language
Condition
Institutional preference
• Use the same pain scale throughout the hospital
experience
▫ Document the use of a differing scale, if changed
• Educate the child/parent/caregiver about the use of the scale
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Assessment Tools: Birth - 6 months
Measurement Scale
Description
Neonatal Infant Pain Scale (NIPS)
Behavioral scale. NIPS assesses facial expression, cry,
breathing patterns, movement of arms and legs, and state
of arousal 30
Age range: Preterm and full term
neonates
Neonatal Pain Assessment and Sedation
Scale (N-PASS)
Age range: Preterm and full term
neonates
Neonatal Facial Coding System (NFCS)
Age range: 32 weeks gestation to
6months
CRIES
Age range: 32 weeks gestation to 6
months
Behavioral and physiologic scale. N-PASS assesses vital
signs (heart rate, respiratory rate, blood pressure, and
oxygen saturation), extremity tone, facial expression,
behavior state, and crying irritability 24,25,30,31
Facial muscle group movement, brow budge, eye squeeze,
nasolabial furrow, open lips, stretch mouth lip purse, taut
tongue, and chin quiver32
Behavioral and physiologic scale. Each of five categories is
scored from 0 to 2: crying; requires O2 for saturation above
95%; increased vital signs (arterial pressure and heart rate);
expression—facial; and sleeplessness30,33
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Assessment Tools: Infant and older
(non-verbal children)
Measurement Scale
Description
Revised Faces, Legs, Activity, Cry, and
Consolability (r-FLACC)
Behavioral scale. Assesses behaviors including: face, legs,
arms, cry, and consolability. The revised scale includes
behaviors most consistently associated with pain in
children with cognitive impairments as well as parentidentified unique behaviors specific to their child. Note: rFLACC contains the same core components as the original
FLACC therefore the revised scale is still appropriate for
non-cognitively impaired children.15,29,34
Age range: Two months to three years,
critically ill, cognitively impaired children,
and those children older than three years of
age unable to utilize a self-report scale.
Non Communicating Children’s
Pain Checklist (NCCPC-R)
Age range: 3-19 years (with cognitive
impairment)
30 items that assess seven dimensions: vocal,
eating/sleeping, social, facial, activity, body/limb, and
physiologic signs35
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Assessment Tools: 3 years and older
Measurement Scale
Description
Wong Baker Faces
Self-report scale. Consists of 6 cartoon faces ranging from a very
happy smiling face depicting no pain to a tearful sad face
depicting worst pain. Note: there are a variety of modified
faces scales. Please refer to specific references for those
alternative face scales.36-38
Age range: 3 years and older
Oucher
Age range: 3 -12 years
Self-report tool consisting of a vertical numerical scale and a
photographic scale with expressions of “hurt” to “no hurt.”
Utilizes actual pictures of children’s faces to estimate pain
intensity.37,39,40
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Assessment Tools: 8 years and older10
Measurement Scale
Description
Visual Analogue Scale (VAS)
Self-report scale. Consists of pre-measured vertical or
horizontal line, where the ends of the line represent
extreme limits of pain intensity. There are many
versions of the VAS in the literature (some with anchor
terminology, presence or absence of divisions along the
line, units of measurement, length, and layout).
Requires understanding of numbers, addition and
subtraction.37,41,42
Self-report scale. Eleven point scale. Children are asked
to rate their pain using numbers with 0 representing
the least amount of pain and 10 the worst amount of
pain. Requires understanding of numbers, addition and
subtraction 40
Age range: 8 years and older
Verbal Numeric Scale (VNS)/ Numeric Rating
Scale (NRS)
Age range: 8 years and older
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Pain score as a measure of
effectiveness15,43
• Children are more than their
score alone
▫ May have distress or
anxiety
▫ May not have recovered
functionally
▫ Pain score meaning and
response to treatment are
complex
Reassessment should include all
assessment elements not just a
pain score.
• In a pain study of young
children postoperatively,*
they had difficulty
distinguishing between
▫ Pain
▫ Nausea
▫ Anxiety
*It is not known if the above
is true in the ED setting
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Pain score interpretability15,43
• Interpretability = clinical meaningfulness of the pain score
• Compares pain scores with pain categories
▫ Mild, moderate and severe vs. 0-10 score
• Studies show pain scores overlap when categorized
▫ An individual child’s pain score may or may not be equivalent to
mild/moderate/severe or satisfaction with pain relief
▫ Variability in perceptions of pain relief makes pain score
interpretation difficult
▫ Girls tended to be satisfied with pain relief at higher scores than
boys
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Summary
• Self-report of pain is the most reliable
• Understanding developmental differences is critical
in assessing pain and understanding children’s
behavior
• Pain score meaning and response to treatment are
complex processes
• Pain reassessment includes all the assessment
elements, not just the pain score
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Collaborate as pain team members
▫
▫
▫
▫
▫
▫
▫
▫
Child
Parent/Caregiver
EMS staff
Nurse
APN
Physician
Pharmacist
Child Life Specialist
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Child Life Specialist20
• Child Life Specialist - specially trained to provide
developmental, educational, and therapeutic
interventions for children and their families in the
healthcare setting
▫ Provide psychosocial preparation for tests, surgeries, and other procedures.
▫ Facilitate medical play using special dolls, stuffed animals and medical
equipment to prepare children for what they are going to hear, see, and feel in
honest, yet soft and relatable language
▫ Reduce overall anxiety to help prevent a negative medical experience20
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Promote family-centered care44
• Integrate family-centered care into practice
▫ Treat all with respect
▫ Communicate with unbiased information
▫ Encourage patient and family participation in the
individualized plan of care, including pain management
• Family-centered care leads to improved
▫ Health outcomes
▫ Patient satisfaction
▫ Provider satisfaction
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Promote pediatric patient safety
• Team members:
▫ Share information to define the plan of care
▫ Implement evidence based approaches to reduce
errors9
 Identify the patient
 Collect allergy information
 Document weight taken
in kilograms
Best Practice:
Weigh the patient on
a kilogram only
scale.8,45
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Team Communication
Discuss and document
▫ Allergies
▫ Physiologic data
▫ Weight8,45
▫ Previous pain history
▫ Pain scale used
▫ Child’s pain rating
▫ Anticipated painful
procedures
▫ Proposed interventions
Used with permission from Microsoft
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Pain assessment, intervention,
reassessment, and disposition process
Assessment
Reassessment46
• Assess for pain at triage
• Explain assessment to child and
parent
• Determine intervention needed
• Explain intervention
• Document
Interventions
•Timing is determined by the
intervention chosen
• Document intervention(s)
• Document instruction provided
• Continue to reassess after each
intervention until discharge
Disposition
•Home
•Admission
•Surgery
•Transfer
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Patient discharge
Create a written discharge
pain plan:
Used with permission from Illinois EMSC
1. Review ongoing
treatment at home
2. Discuss what to do if pain
worsens
3. Arrange follow up with
primary care provider
4. Consider referral to case
manager, pain
specialist/service, or
palliative care team for
chronic pain conditions
5. Document instructions
reviewed and given
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Summary
• A multidisciplinary team approach should be
accessible to every child in the ED
• Effective pain management requires:
▫ Team communication
▫ Attention to patient safety
▫ Adherence to family-centered care principles
• Pain reassessment is an ongoing team process
throughout the child’s hospitalization
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Pain interventions that alter
peripheral transmission of pain47
Transmission Point
Peripheral transmission of pain impulses
▫ Reduce tissue injury
▫ Alter blood flow to area
▫ Reduce swelling
▫ Inhibit prostaglandin production
Transmission Altering Interventions
Non-pharmacologic
Splinting
Immobilization
Skin stimulation
Application of heat and cold
Touch
Pharmacologic
Administer non -steroidal anti-inflammatory drugs (NSAIDs)
Ibuprofen, Ketorolac
Administer local anesthetic agent
Lidocaine
Applied to site of injury
Applied regionally
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Pain interventions that alter
spinal cord transmission of pain47
Transmission Point
Spinal cord :
▫ Block by activating large fibers and preventing nociceptive transmission
▫ Block by binding opioid receptors in the spinal cord
▫ Decrease release of neurotransmitters
▫ Interrupt the descending input from the brain
Transmission Altering Interventions
Non-pharmacologic
Skin stimulation
Massage
Acupuncture
Application of heat and cold
Touch
Pharmacologic
Epidural analgesia
Intrathecal analgesia
Opioids
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Pain interventions that alter
receptor site transmission of pain47
Transmission Point
Receptor sites throughout the body and the brain
▫
▫
▫
Increase stimuli to the brain
Increase blood flow to targeted areas, decreases pain chemicals
Increase endorphins
Transmission Altering Interventions
Non-pharmacologic
Distraction
Imagery
Relaxation
Biofeedback
Pharmacologic
Systemic opioids
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Non-pharmacologic intervention
categories20,27,28
Child’s Support
Group
Developmental
interventions
ED
environment
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Child’s sources of support
Parent/
Caregiver
Friend(s)
Previous
experience
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Environmental resources20,28
Music
TV
Room
amenities
Toys,
books,
games
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Non-pharmacologic
Interventions13,20,28,48
• Non-pharmacologic and pharmacologic methods can
work together effectively
• Educate and encourage the parent/caregiver to
participate in non-pharmacologic techniques
• Distraction
• Passive distraction: child is engaged without any effort
on their part
• Active distraction: child participates in an activity
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Non-pharmacologic measures infants13,28
•
•
•
•
Swaddling
Holding
Rocking
Sucking
▫ Sucrose pacifier49
▫ Non-nutritive sucking
•
•
•
•
Dim lighting
Music
Picture reading
Toys
▫ Key chains
▫ Rattles
▫ Blocks
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Non-pharmacologic measures toddlers13,28
•
•
•
•
•
Provide distraction with music
Provide a pacifier
Provide light touch or massage
Try repositioning, splinting
Apply cold or hot pack
•
•
•
•
•
Offer play with blocks
Drawing with crayons and paper
Encourage picture reading
Encourage singing
Blowing bubbles
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Non-pharmacologic measures –
pre-schoolers13,28
•
•
•
•
•
•
Provide a calm environment
Apply cold or hot pack
Provide a position of comfort
Provide light touch or massage
Suggest music or TV to entertain
Coach child through the ED
process and/or procedures
•
•
•
•
•
•
Draw in coloring books
Play with puzzles
Look at or read storybooks
Encourage singing or storytelling
Hold cold or hot pack
Engage in distracting
conversation
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Non-pharmacologic measures –
school age child13,28,50
• Provide a calm environment
• Suggest new positions for
comfort
• Suggest music, TV
• Read books
• Coach child through the ED
process and/or procedures
• Share jokes
• Provide light touch or massage
• Hold cold or hot pack
• Demonstrate relaxation
techniques such as breathing
exercises
• Use squeeze balls
• Encourage conversation about
favorite things
• Play with electronic
tablet/wireless internet device
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Non-pharmacologic measures adolescent13,28,51
• Apply cold or hot pack
• Suggest repositioning or
positions of comfort
• Encourage talking about favorite
places or activities
• Provide light touch or massage
• Listen to music
• Read
• Visit with friend
• Use telephone access
• Coach about ED processes and
procedures
• Discuss preferred relaxation
techniques
• Demonstrate relaxation
techniques, if unfamiliar
• Use squeeze balls
• Encourage making choices
• Play with electronic games or
tablets
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Summary
• The child’s age, cognitive abilities, the type of pain,
and the environment, must be considered when
selecting a non-pharmacologic intervention
• Parental presence is a significant supportive
mechanism for children
• Parent/caregiver and child benefit from instruction
specific to the use of non-pharmacologic techniques
in pain management
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81
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Pharmacologic pediatric pain
management barriers20
Used with permission from Microsoft
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Incorporate evidence-based
pharmacologic pain interventions48
• Provide analgesia for children
with abdominal pain prior to the
surgical consult
• Apply topical anesthetics prior to
IV insertions, blood draws and
laceration repairs
• Provide pain medication for
children in triage with a pain
rating greater than 6 out of 10
• Provide pressure to IM site
before giving injections
• Provide anesthetic ear drops for
ear pain
• Use lidocaine as a diluent if
giving IM ceftriaxone
• Use buffered lidocaine for local
anesthesia
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Topical anesthetics52-54
AGENT
L.M.X.4®
(Lidocaine 4%)
INDICATION
DOSE/ROUTE
For external use for pain Apply externally
relief of minor cuts,
scrapes, burns, sunburn,
insect bites, and minor
skin irritations
TIME ONSET/
DURATION
Onset 20-30 minutes
MAXIMUM DOSE
Externally 3-4 times per
day
Duration 60 minutes
Apply in area less than
100cm2 for children less
than 10 kg
Apply in area less than
600cm2 for children
between 10 and 20 kg
LET
Lidocaine
Epinephrine
Tetracaine
(gel or liquid)
Wound repair
(non-mucosal)
Per pharmacy protocol
Topical
4% Lidocaine
1:2,000 Epinephrine
0.5% Tetracaine
Onset 10 minute
Duration 30-60 minute
3 ml
(not to exceed maximal
Lidocaine dosage of
3-5 mg/kg)
COMMENTS
Advantages
For use in children 2
years and older
over-the-counter (OTC)
availability
Risks
Discuss use with
physician in children
under 2 years old.
Advantages
No physical wound
distortion, painless
application, decreased
repair time, non-cocaine
containing anesthetic
Risks
Not for use over end
arteriole locations
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AGENT
INDICATION
EMLA
(2.5% Lidocaine
2.5% Prilocaine)
Dermal analgesic
(intact skin)
(for children > 3 months
age)
AGE/DOSE/ROUTE
3-12 months (and >5 kg)
maximum area covered
20 cm2
TIME ONSET/
DURATION
Onset 60 minutes
MAXIMUM DOSE
2 gm*
Duration 3-4 hour
1-6 years (and >10 kg)
maximum area covered
100 cm2
10 gm*
7-12 years (and >20 kg)
maximum area covered
200 cm2
20 gm*
topical/transdermal (cover
area with occlusive
dressing)
NOTE: *Dosages are guidelines to avoid
systemic toxicity in patients with normal
intact skin and with normal renal and
hepatic function
COMMENTS
Advantages
Painless application,
patient compliance,
decreased repair time
Risks
Methemoglobinemia,
contact dermatitis
Maximum application
time not to exceed 4
hours
(If a patient does not
meet the minimum
weight requirement, the
maximum total dose
should be restricted to
that which corresponds
to the patient’s weight)
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Topical anesthetics52-55
AGENT
Pain-Ease®
INDICATION
Cooling intact skin and
mucus membranes and
minor open wounds
DOSE/ROUTE
Spray for 4-10 seconds
from a distance of 8-18
cm
TIME ONSET/
DURATION
MAXIMUM DOSE
Onset- immediate
When skin turns white
Duration- a few seconds,
up to a minute
COMMENTS
Advantages
Quick acting
Risks
Skin freezing may create
hypopigmentation
especially in dark pigment
skin
Viscous Lidocaine
Foley catheter and
nasogastric tube
insertion;
intubation
2%- 4% topical jelly
Onset 2-5 min
Duration 30-60 min
3-5 mg/kg
Advantages
Comfort of insertion,
lubrication for insertion
10% spray
NOTE: Not recommended for teething
children or young children who cannot
expectorate.
Risks
Hematoma, painful,
bleeding at site,
absorption can cause
systemic toxicity.
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Infiltrative anesthetics52-55
AGENT
Infiltrative Lidocaine
INDICATION
Vascular access; needle
insertion procedures
DOSE/ROUTE
Subcutaneous
1% Lidocaine with
epinephrine
TIME ONSET/
DURATION
Onset 4-10
minutes
Duration 90-120
minutes
0.5% Lidocaine with
epinephrine
1% or 0.5% plain Lidocaine
J-Tip®
Jet injector of 1%
buffered Lidocaine
Vascular access, needle
insertion procedures
0.2 ml
subcutaneous
MAXIMUM DOSE
Immediate
7mg/kg to a maximum of
500 mg
COMMENTS
Advantages
Rapid onset, longer
duration
Risks
4.5 mg/kg to a maximum of Hematoma, bleeding at
300 mg
site; absorption can
cause systemic toxicity
Additional dosing after
maximum reached, may
occur after 2 hours.
One application per site
Advantages
Needleless
Risks
Not for preterm infants;
neonates; patients with
blood disorders; or in
children receiving
chemotherapy or blood
thinners.
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Pharmacologic pain approaches and
interventions56
By
mouth
By the
ladder
Pharmacologic
Pain
Management
By the
child
By the
clock
88
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By mouth56
By
mouth
• Promote use of least invasive,
most effective agent
• IV route is reserved for moderate
to severe pain
• Avoid intramuscular route
Used with permission from Microsoft
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By the
clock
By the clock56
• Promote pain relief with timely
and routine dosing
• Start with a dose that matches
both the pain assessment
findings and pain score
• Titrate dose upward if relief is
inadequate
Used with permission from Microsoft
• Modify intervals between doses
in the presence of moderate and
severe pain
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By the
child
By the child20,55,56
• Incorporates the child’s
▫
▫
▫
▫
▫
Used with permission from Illinois EMSC
Developmental status
Cultural influences
Religious concerns
Personal preferences
Previous pain experiences
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By the
ladder
WHO Pain Ladder56,57
• Originally created for guiding
cancer pain treatment
• Uses a three-step ladder
• Uses least invasive administration
route to provide needed
analgesic
• Recommends use of adjuvants to
manage side effects, minimize
fear, and enhance pain relief
Used with permission. Cancer Pain Relief and Palliative Care in
Children. World Health Organization 1998.
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Mild pain agents52-54
NON-OPIOID
Acetaminophen (APAP)‡
INDICATION
Mild pain
DOSE/ROUTE*
MAX DOSE
10 - 15 mg/kg 75 mg/kg/day
Every 4-6 hr
COMMENTS
Advantages
Minimal adverse effects on GI tract or renal function
Risks
Liver toxicity
PO, PR
NOTE: ‡ All doses of
combination products limited by
APAP content to 75 mg/kg
Ibuprofen
(Motrin®, Advil®)
Mild pain
5 - 10mg/kg
Every 6-8 hr
PO
40 mg/kg/day
Advantages
Inhibits prostaglandin-induced nociception
Risks
Nausea, vomiting, ulcers, platelet dysfunction, liver toxicity
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Moderate pain agents52-54
NON-OPIOID
Ketorolac
(Toradol®)
DOSE/ROUTE*
INDICATION
Moderate - severe pain
0.25 mg – 1 mg/kg every 6 hr
MAX DOSE
30 mg every 6 hr
IV, IM*
PO for patients > 50 kg
COMMENTS
Advantages
Effective alternative to opioids for
treatment of moderate to severe
pain
Risks
Bleeding diathesis; hyperkalemia;
depression of renal function; and
hepatotoxicity
NOTE: Do not use with other
NSAIDs.
NOTE: Meperidine (Demerol®) is not
recommended due to its potential for
prolonged side effects from active metabolites,
lowered seizure threshold, and renal
insufficiency.
*IM routes not recommended as first line treatment.
94
.
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Moderate pain agents52-54
OPIOIDS§
Codeine/APAP
with Codeine
DOSE/ROUTE*
INDICATION
Mild - moderate
pain
0.5 - 1mg/kg of
Codeine
ONSET
1-2 hr
DURATION
4-6 hr
MAX DOSE
60 mg/dose
Every 4-6 hr
PO
COMMENTS
Advantages
Rapid onset action, minimal
respiratory depression orally
Risks
Nausea, vomiting, constipation,
respiratory depression,
hypotension, bradycardia, CNS
depression
NOTE: Codeine is ineffective in
1/3 of patients.
NOTE: Ibuprofen has provided equivalent
pain relief when compared to codeine
alone or acetaminophen with codeine. 58,59
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Moderate pain agents52-54
OPIOIDS
Hydrocodone
(+ APAP: Lortab®
Vicodin®)
INDICATION
DOSE/ROUTE*
Mild 0.1 - 0.2 mg/kg of
moderate pain Hydrocodone
ONSET
30 min
DURATION
3 - 4 hr
MAX DOSE
Limited by APAP
component
Every 4-6 hr
(+APAP: Percocet®)
Moderate severe pain
0.05 - 0.15 mg/kg
of Oxycodone
15 min
3 - 4 hr
10 mg every 4-6 hr
Every 4-6 hr
PO (immediate
release formula)
Advantages
Oral medication,
moderately rapid onset
Risks
Dizziness, sedation,
nausea, vomiting,
constipation
PO
Oxycodone
COMMENTS
NOTE: Generally not
recommended in children
less than 6 years of age.
Advantages
Oral medication,
moderately rapid onset
Risks
CNS depression,
respiratory depression,
hypotension, bradycardia,
nausea
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Severe pain
• Use high potency analgesics
▫ Morphine
▫ Fentanyl
▫ Hydromorphone
Myth:
Children can
become easily
addicted if given
narcotics
• Intractable pain may require:
▫ Nerve block, epidural or patient controlled analgesia
(PCA)60
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Intranasal Fentanyl
• Intranasal administration is
helpful in meeting pain relief for
long bone fractures.61,62
Used with permission from Illinois EMSC
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Severe pain52-54
OPIOIDS
Fentanyl
(Sublimaze®)
DOSE/ROUTE*
INDICATION
Moderate severe pain
ONSET
DURATION
1-2 mcg/kg/dose
IV (administer over 3-5
minutes)
1-2 min IV
30-60 min IV
IN (divide dose equally
between each nostril)
10 min IN
60 min IN
IM*
7-15 min IM
1-2 hr IM
NOTE: IN route should not be used in
patients with facial trauma.
*IM routes not recommended as first line treatment.
MAX DOSE
COMMENTS
1-3 mcg/kg/dose Advantages
Rapid onset, short duration,
potent analgesic; preferred
medication for renal patients
Risks
Respiratory depression, apnea
may precede alteration of
consciousness chest wall
rigidity if given too rapidly
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Severe pain52-54
OPIOIDS
Morphine
(Roxanol®)
INDICATION
Moderate severe pain
DOSE/ROUTE*
0.2 - 0.5 mg/kg
IV, SC, IM*
ONSET
5-15 min
DURATION
3-4 hr
MAX DOSE
15 mg
Every 4-6 hr
0.1 - 0.2 mg/kg
PO (immediate
release formula)
Every 2-4 hr
Advantages
Moderately rapid predictable
onset. Significant role for
patients who need prolonged
pain control (e.g., fracture
reduction, multiple trauma,
sickle cell disease)
Risks
Respiratory depression,
hypotension, bradycardia, CNS
depression
NOTE: Avoid in children with renal failure.
*IM routes not recommended as first line treatment.
COMMENTS
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Severe pain52-54
OPIOIDS
Hydro-morphone
(Dilaudid®)
INDICATION
Severe pain
DOSE/ROUTE*
0.015 mg/kg
IV
ONSET
DURATION
Almost
immediately
2-4 hr
Up to 30 min
4-5 hr
Every 4 hr
0.03 - 0.08 mg/kg
PO
Every 4 hr
MAX DOSE
COMMENTS
0.015 mg/kg/dose Advantages
Rapid onset; less pruritis
Every 4 hr
than morphine
Risks
Respiratory depression,
CNS depression, sedation
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Use of adjuvants46
Coanalgesics
Drugs to combat side effects
•
•
•
•
•
•
•
•
Antidepressants
Anticonvulsants
Corticosteroids
Sedative/hypnotics
Anti-emetics
Antihistamines
Psychostimulants
Neuroleptics
Remember, children have
difficulty distinguishing
between pain, nausea and
anxiety.
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EMSC 2013
Summary
• Pharmacologic approaches include: by mouth, by the
clock, by the child and by the ladder
• The least invasive, best match for the severity of pain
is the preferred analgesic choice
• Integrating evidence-based pharmacologic
interventions provides effective pain management
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Quality monitoring63,64,65
• Activities to evaluate care
• Selected by organizations to:
▫ Ensure quality care
▫ Monitor outcomes of care
▫ Respond to outcomes that are below acceptable
standards
▫ Identify and promote best practices
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EMSC 2013
Tools that support quality63,64,65
•
•
•
•
•
•
Multidisciplinary committee work
Policy
Procedure
Guidelines, pathways, frameworks, protocols
Ongoing staff training
Safety culture
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Practice improvement terminology65
• Quality control
▫
A set of activities whose purpose is to guarantee that all quality requirements are being met. The
organization monitors processes and provides solutions to performance problems to achieve this
purpose.
• Quality of care, treatment, and services
▫
The degree to which care, treatment, or services for individuals and populations increases the
likelihood of desired health outcomes. This includes the appropriateness, efficacy, efficiency,
timeliness, accessibility, and continuity of care; and the safety of the care environment.
• Guideline, practice parameter, protocol description
▫
An evidence-based document about best practice processes, developed by consensus opinion of
experts, for evaluating and/or treating a patient, who has a specific symptom, condition, or diagnosis.
• Policy
▫
A principle or method that is developed for the purpose of guiding decisions and activities related to
care, treatment, and services.
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Elements of pediatric pain guideline,
protocol, policy, and order sets
• Evidence-based
• Age of target population
• Expected behaviors by role
▫ Assessment
AAP, ASPMN
and ENA
endorsed 9,20
 Initiation
 Reassessment
▫ Actions to take when a specific symptom, condition or
diagnosis are present45
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EMSC 2013
Tools to improve the timeliness of
interventions
• Create with multidisciplinary
consensus
•Musculoskeletal pain
•Ear pain
•Eye pain
• Determine format
•Algorithm
Practice
Guideline
Algorithm
Quality
monitors
Policy and
procedure
▫ Based on facility preferences
• Review and revise at specified
intervals
• Allow comparison between the
care standard and the actual care
provided
•Audit tool #1
•Audit tool #2
•Policy and
Procedure
109
Rapid
Cycle
Model66
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What are we trying
to accomplish?
Setting Aims
How will we know
that a change is an
improvement?
Establishing Measures
What changes can
we make that will
result in
improvement?
Selecting Changes
Example:
Improving pain reassessment,
of children less than 15 years old, prior to disposition
Example:
90% of discharge pediatric medical records
have a reassessment documented prior to disposition
Examples:
Post pain scale in patient area
Offer education or competency
Change order set
Seek solutions through debriefing of pain cases
Evaluating Changes
Act
Study
Plan
Do
Example:
Review and analyze the data after
implementing one of the above changes
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Rapid Cycle Improvement Model
Setting Aims
What are we trying
to accomplish ?
Improvement requires setting aims. The aim
should be time-specific and measurable and
define the specific population of patients
that will be affected.
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Rapid Cycle Improvement Model
Establishing
Measures
How will we know a
change is an
improvement?
Use quantitative measures to determine if
specific changes actually lead to an improvement.
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EMSC 2013
Rapid Cycle Improvement Model
What changes can we
make that will result in
an improvement ?
All improvement requires making changes, but not
all changes result in improvement. Identify the
changes that most likely will lead to improvement.
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EMSC 2013
Rapid Cycle Improvement Model
Act
Plan
Study
Do
The Plan-Do-Study-Act (PDSA) cycle is used for testing
change in an actual setting, by planning it, doing it,
checking the results, and acting on what is learned.
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EMSC 2013
Summary
• Quality monitoring should be incorporated into your
facility’s pain management program
• Quality monitoring is a multidisciplinary process
• Organizations improve the care process by utilizing
tools to standardize care
• The Rapid Cycle Improvement model provides a
framework for improving care quality by testing
changes in care for effectiveness
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Thank you
Used with permission from Illinois EMSC
116
EMSC 2013
Appendix A: PSA reference list
1. American College of Emergency Physicians. The use of pediatric sedation and analgesia. Ann Emerg Med. 2008;52(5):595-596.
2. Atkinson P, Chesters A, Heinz P. Pain management and sedation for children in the emergency department. BMJ.
2009;339:b4234.
3. Babl FE, Mandrawa C, O'Sullivan R, Crellin D. Procedural pain and distress in young children as perceived by medical and
nursing staff. Paediatr Anaesth. 2008;18(5):412-419.
4. Bhatt M, Currie GR, Auld MC, Johnson DW. Current practice and tolerance for risk in performing procedural sedation and
analgesia on children who have not met fasting guidelines: A Canadian survey using a stated preference discrete choice
experiment. Acad Emerg Med. 2010;17(11):1207-1215.
5. Bhatt M, Kennedy RM, Osmond MH, et al. Consensus-based recommendations for standardizing terminology and reporting
adverse events for emergency department procedural sedation and analgesia in children. Ann Emerg Med. 2009;53(4):426435.e4.
6. EMSC Panel on Critical Issues in the Sedation of Pediatric Patients in the Emergency Department. Ann Emerg Med.
2008;51(4):378-399.e57.
7. Green SM, Roback MG, Kennedy RM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative
sedation: 2011 update. Ann Emerg Med. 2011;57(5):449-461.
8. McDonnell WM, Guenther E, Larsen LF, Schunk J. The reimbursement gap: Providing and paying for pediatric procedural
sedation in the emergency department. Pediatr Emerg Care. 2009;25(11):797-802.
117
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Appendix B: Module references
1. HCUP Nationwide Emergency Department Sample (NEDS). Healthcare Cost and Utilization Project (HCUP). 2007, 2008, 2009.
Agency for Healthcare Research and Quality, Rockville, MD. Web site. http://www.hcup-us.ahrq.gov/nedsoverview.jsp. Accessed
7/12/2012.
2. Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med.
2003;41(5):617-622.
3. Probst BD, Lyons E, Leonard D, Esposito TJ. Factors affecting emergency department assessment and management of pain in
children. Pediatr Emerg Care. 2005;21(5):298-305.
4. Drendel AL, Brousseau DC, Gorelick MH. Pain assessment for pediatric patients in the emergency department. Pediatrics.
2006;117(5):1511-1518.
5. Rogovik AL, Rostami M, Hussain S, Goldman RD. Physician pain reminder as an intervention to enhance analgesia for
extremity and clavicle injuries in pediatric emergency. J Pain. 2007;8(1):26-32.
6. Dong L, Donaldson A, Metzger R, Keenan H. Analgesic administration in the emergency department for children requiring
hospitalization for long-bone fracture. Pediatr Emerg Care. 2012;28(2):109-114.
7. Galinski M, Picco N, Hennequin B, Raphael V, Ayachi A, Beruben A, Lapostolle F, Adnet F. Out-of-hospital emergency medicine
in pediatric patients: prevalence and management of pain. American Journal of Emergency Medicine.2011;29:1062–1066.
8. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians,
Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement-guidelines for care of children
in the emergency department. Pediatrics. 2009;124(4):1233-1243.
118
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Appendix B:
Module references 9-16
9. Emergency Nurses Association, American Society for Pain Management Nursing.
Optimizing the treatment of pain in patients with acute presentations . Emergency Nurses Association Web site.
http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Pain_Mgmt_pol.pdf. Updated July 2009. Accessed
1/3/2012.
10. Franck L, Greenberg C, Stevens B. Acute pain in children: Pain assessment in infants and children. Pediatr Clin North Am.
2000;47(3):487.
11. Fitzgerald A, Anand KJS. Development Neuroanatomy and Neurophysiology of pain. In: Schecter NL, Berde CB, Yaster M,
eds. Pain in infants, children, and adolescents. Baltimore: Williams and Wilkins; 1993:11.
12. Helms JE, Barone CP. Physiology and treatment of pain. Critical Care Nurse. 2008;2008(28):38.
13. Illinois Emergency Medical Services for Children (EMSC), ed. Pediatric pain management in the emergency department
educational module, August 2002; 2002.
14. Anand KJS, Phil D, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative
analgesia in cardiac surgery. The New England Journal of Medicine. 1992;326(1):1.
15. Drendel, A , Kelly, BT, Ali, S. Pain Assessment for Children Overcoming Challenges and Optimizing Care. Pediatr Emerg Care.
2011;27(8):773.
16. von Baeyer CL, Marche TA, Rocha EM, Salmon K. Children's memory for pain: Overview and implications for practice. Journal
of Pain. 2004;5(5):241-249.
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Appendix B:
Module references 17-24
17. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G. Effect of neonatal circumcision on pain responses during vaccinations of
boys. The Lancet. 1995;345:291.
18. Grunau R, Whitfield M, Petrie J. Pain sensitivity and temperament in extremely low-birth-weight premature toddlers and
pre-term and fullterm controls. Pain. 1994;58:341.
19. APS press room. American Pain Society Web site. www.ampainsoc.org/. Accessed November 14, 2012.
20. Fein J, Zempsky W, Cravero J, Committee on the Pediatric Emergency Medicine and Section on Anesthesiology and Pain
Medicine. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2012;130(5):11/13/2012.
21. Child, Adolescent & "Catch-up" Immunization Schedules Details For Health Care Professionals Web site.
http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html. Updated June 2012. Accessed 8/2/2012.
22. Perquin CW, Hunfeld JAM, Hazebroek-Kampschreurc AAJM, et al. Insights in the use of health care services in chronic benign
pain in childhood and adolescence. Pain. 2001;94:205.
23. Emergency Nurses Association. Pediatric procedural pain management. ENA Position Statement Web site.
http://www.ena.org/about/position/position/Pages/Default.aspx. Published 12/2010. Updated 2010. Accessed 3/20/2012.
24. Hummel P, Puchalski M, Greech S, Weiss M. Clinical reliability and validity of the N-PASS: Neonatal pain, agitation and
sedation scale with prolonged pain. Journal of Perinatology. 2008;28(1):55.
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Appendix B:
Module references 25-32
25. Hummel P, Van Dijk M. Pain assessment: Current status and challenges. Seminars in Fetal Neonatal Medicine.
2006;11(4):237.
26. Oakes LL. Compact Clinical Guide to Infant and Child Pain Management: an Evidence based Approach for Nurses. New York:
Springer; 2011.
27. Stanford EA, Chambers CT, Craig KD. A normative analysis of the development of pain-related vocabulary in children. Pain.
2005;114:278.
28. Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: Assessment and non-pharmacological management. International
Journal of Pediatrics. 2010;474838.
29. Voepel-Lewis T, Merkel S, Tait A, Trzcinka A, Malviya S. The reliability and validity of the face, legs, activity, cry, consolability
observational tool as a measure of pain in children with cognitive impairment. Anesthesia & Analgesia. 2002;95:1224.
30. Spasojevic S, Bregun-Doronjski A. A simultaneous comparison of four neonatal pain scales in clinical settings . Journal of
Maternal-Fetal & Neonatal Medicine. 2011;24(4):590.
31. Hummel P, Lawlor-Klean P, Weiss M. Validity and reliability of the N-PASS assessment
tool with acute pain. Journal of Perinatology. 2010;30(7):474.
32. Ahola Kohut S, Pillai Riddell R. Does the neonatal facial coding system differentiate between infants experiencing painrelated and non-pain-related distress? Journal of Pain. 2009;10(2):214.
121
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Appendix B:
Module references 33-41
33. Krechel S, Bildner J. CRIES: A new neonatal postoperative pain measurement score– initial testing of validity and reliability.
Paediatric Anaesthesia. 1995;5:53.
34. Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait A. The revised FLACC observational pain tool: Improved reliability and
validity for pain assessment in children with cognitive impairment. Pediatric Anaesthesia. 2006;16(3):258.
35. Breau L, Finley G, McGrath P, Camfield C. Validation of the non-communicating children’s pain checklist-postoperative
version. Anesthesiology. 2002;96(3):528.
36. Garra G, Singer AJ, Taira BR, et al. Validation of the Wong-Baker FACES pain rating scale in pediatric emergency department
patients. Acad Emerg Med. 2010;17(1):50-54.
37. Stinson J, Kavanagh T, Yamada J, Gill N, Stevens B. Systematic review of the psychometric properties, interpretability and
feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain. 2006;125(12):143.
38. Wong D, Baker C. Pain in children: Comparison of assessment scales. Pediatric Nursing. 1988;14(1):9.
39. Beyer J, Denyes M, Villarruel A. The creation, validation, and continuing development of the Oucher: A measure of pain
intensity in children. Journal of Pediatric Nursing. 1992;7(5):335.
40. Luffy R, Groves S. Examining the validity, reliability, and preference of three pediatric pain measurement tools in African
American children. Pediatric Nursing. 2003;23(1):54.
41. Bailey B, Bergeron S, Gravel J, Daoust R. Comparison of four pain scales in children with acute abdominal pain in a pediatric
emergency department. Academic Emergency Medicine. 2007;14(5):S90.
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Appendix B:
Module references 42-50
42. Shields B, Cohen D, Harbeck-Weber C, Powers J, Smith G. Pediatric pain measurement using a visual analogue scale: A
comparison of two teaching methods. Clinical Pediatrics. 2010;42:227.
43. Voepel-Lewis T. Commentary pain assessment and decision making: Have we missed the mark? Special Interest Group on
Pain in Childhood, International Association for the Study of Pain. 2011;13(1):1.
44. Committee on the Future of Emergency Care in the United States Health System. Emergency Care for Children: Growing
Pains. Washington, DC: The National Academies Press, 2007
45. Emergency Nurses Association. Weighing pediatric patients in kilograms. Emergency Nurses Association Position
Statement Web site. http://www.ena.org/SiteCollectionDocuments/Position%20Statements/WeighingPedsPtsinKG.pdf.
Published August 2012. Updated March 2012. Accessed 8/24/2012.
46. Hockenberry M, Wilson D, eds. Wong’s Nursing Care of Infants and Children 8th ed. St. Louis: Mosby; 2007.
47. Copstead LC, Banasik J. Pathophysiology. Vol 12. 4th ed. Canada: Elsevier; 2010:900.
48. Kleiber C, Jennissen C, McCarthy AM, Ansley T. Evidence-based pediatric pain management in emergency departments in a
rural state. The Journal of Pain. 2011;12(8):900.
49. Curtis SJ, Jou H, Ali S, Vandermeer B, Klassen T. A randomized controlled trial of sucrose and/or pacifier as analgesia for
infants receiving venipuncture in a pediatric emergency department. BMC Pediatr. 2007;7:27.
50. Chambers CT, Taddio A, Uman LS, McMurty CM, HELPinKIDS Team. Psychological interventions for reducing pain and distress
during routine childhood immunizations: A systematic review. Clinical Therapeutics. 2009;31(Supplement B):S77.
123
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Appendix B:
Module references 51-59
51. Uman LS, Chambers CT, McGrath PJ, Kisely SR. Psychological interventions for needle-related procedural pain and distress in
children and adolescents. Cochrane Database of Systematic Reviews. 2006;2006(4):CD005179.
52. Lacy C, ed. Drug Information Handbook. 21st ed. Lexi-Comp; 2012.
53. Young TE, ed. Neofax. 24th ed. Raleigh NC: Thomson Reuters; 2011.
54. Gunn VL, Nechyba C, eds. Harriet Lane Handbook. 16th ed. St. Louis; 2002.
55. Jennissen C, Kleiber C, Ryan A, Pediatric Pain management and Prevention. 1st Edition. University of Iowa; 2011.
56. McGrath PA. Development of the World Health Organization guidelines on cancer pain relief and palliative care in children. J
Pain Symptom Manage. 1996;12(2):87-92.
57. World Health Organization, ed. Cancer Pain Relief and Palliative Care in Children. Geneva: World Health Organization; 1998.
58. Clark E, Plint AC, Correll R, Gaboury I, Passi B. A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for
acute pain relief in children with musculoskeletal trauma Pediatrics. 2007;119(3):460.
59. Friday JH, Kanegaye JT, McCaslin I, Zheng A, Harley JR. Ibuprofen provides analgesia equivalent to acetaminophen-codeine in
the treatment of acute pain in children with extremity injuries: A randomized clinical trial. Acad Emerg Med. 2009;16(8):711716.
124
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Appendix B:
Module references 59-66
60. Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician.
2010;56(6):514.
61. Holdgate A, Cao A, Lo KM. The implementation of intranasal fentanyl for children in a mixed adult and pediatric emergency
department reduces time to analgesic administration. Acad Emerg Med. 2010;17(2):214-217.
62. Borland M, Jacobs I, King B, O'Brien D. A randomized, controlled trial comparing intranasal fentanyl to intravenous morphine
for managing acute pain in children in the emergency department. Ann Emerg Med. 2007;49(3):335-340.
63. Thomas DO. Implementing the IOM recommendations for improving pediatric emergency care in your emergency
department: Start from where you are! Journal of Emergency Nursing. 2010 36(4),375–378.
64. The Joint Commission. (2008, April 11). Preventing pediatric medication errors. Sentinel Event Alert, (39).
http://www.jointcommission.org/assets/1/18/SEA_39.PDF. Accessed 10/1/2012.
65. 2012 The Joint Commission . Standards Manual Content, Glossary Web site. https://e-dition.jcrinc.com/MainContent.aspx.
Published 2012. Updated 2012. Accessed 9/4/2012.
66. Taylor JA, Crowe VL. Rapid cycle change sells itself. Journal for Healthcare Quality. 1999;21(5):4-7.
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Appendix C:
Electronic sites
American Academy of Pediatrics
www.aap.org/en-us/professional-resources/Pages/Professional-Resources.aspx
American College of Emergency Physicians
www.acep.org/
www.ama-assn.org/ama/pub/education-careers/continuing-medicaleducation.page?
American Medical Association
American Pain Society
American Society for Pain Management in
Nursing
www.ampainsoc.org/
Det Norske Veritas Healthcare, Inc
http://dnvaccreditation.com/pr/dnv/default.aspx
Drug Enforcement Administration
www.justice.gov/dea/index.shtml
Emergency Nurses Association
www.ena.org/
Food and Drug Administration
www.fda.gov/ForHealthProfessionals/default.htm
www.aspmn.org/
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Appendix C:
Electronic sites
Healthcare Facilities Accreditation Program
http://www.hfap.org/
Illinois Emergency Medical Services for Children www.luhs.org/emsc
International Association for the Study of Pain www.iasp-pain.org/
National Association of Emergency Medical
System Physicians
http://www.naemsp.org/Pages/default.aspx
National Association of Emergency Medical
Technicians
http://www.ems1.com/partners/national-association-of-emergency-medicaltechnicians-(naemt)
The Joint Commission
http://www.jointcommission.org
World Health Organization
www.who.int/en