Pediatric Prehospital Pain Management: the ED perspective :Pediatric Prehospital Pain Management: the ED perspective Emergency Medicine Symposium October 3, 2008 Michael K. Kim, MD, FAAP Pediatric Emergency Medicine UWSMPH


Objectives :Objectives Historical model Barriers prehspital and ED Evidence based advances and future


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


Issues :Issues Head injury Unable to obtain vital signs Prolonged transport morphine versus fentanyl routes of administration Role of accepting MD/medical control Level of transport service Factors for additional doses


Advancement in pre-hospital care :Advancement in pre-hospital care “scoop and run” GTHTTH “stay and play” “play and run”


Pre-hospital :Pre-hospital 14.5 million EMS transports annually Moderate to severe pain in 20% 50% are children McLean SA, PEC, 2002 Only 6 papers prehospital pain management (1980-1996) Challenges and barriers in prehospital setting Consent Methodology


Statements :Statements “Relieving discomfort may be the most important task EMS providers perform for majority of their patients.” ACEP 1997 “Relief of discomfort is the most relevant outcomes measure for majority of pre-hospital conditions” EMSOP / NHTSA 1999


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


Prehospital opioid administration for fractures :Prehospital opioid administration for fractures


Time to first dose of opioid :Time to first dose of opioid Scoop and run result in significant delay in analgesic administration.


Pain Management Barriers :Pain Management Barriers Provider barriers System barriers Patient barriers


Survey dataHennes, et al. Prehospital Emerg Care 2005;9:32-39 :Survey dataHennes, et al. Prehospital Emerg Care 2005;9:32-39 Reasons for withholding morphine in children Inability to assess pain Patient refusal Drug seeking behavior No indications for vascular access


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


Provider barriersKim et al. 2006 NAEMSP abstract :Provider barriersKim et al. 2006 NAEMSP abstract Doubts the need for pain management Lack of education Pain physiology & pharmacology Difficulty in pain assessment Lack of easy to use assessment tool for children Questions the validity and reliability of tools Negative incentives Need for an IV & difficult IV Transport time Work load Negative feedback from Docs


System barriers :System barriers Lack of education Physiology, assessment, pharmacokinetics, outcomes data Medical control Reluctant to provide pain meds Ricard-Hibbon 1999 & Fullerton-Gleason 2002 Multiple tiered system EMT vs. paramedic


Patient barriers :Patient barriers No pain meds prior to ED (74%) Spedding 1999 harmful hospital’s responsibility not available 70% of adults with severe pain did not ask for pain medication Richrd-Hibbon 1999


ED physicians When should EMS provide analgesia? :ED physicians When should EMS provide analgesia? based on the obvious deformity it’s so easy….just get a doctor and get the morphine Transport time again What if I have a little finger….put an IV in depends too on how bad it actually looks I think if it is obviously deformed they think they should put an IV in Don’t they have to call the doctor if they have an IV?


ED physiciansIs prehospital pain management a benefit? :ED physiciansIs prehospital pain management a benefit? Yes Calmer patients Expedites evaluation If it is grossly deformed, no problem No If short transport time Unable to evaluate If they mess up…


ED physicians Focus group summary 2004 :ED physicians Focus group summary 2004 Not aware of pain protocols Limited experience with prehospital pain management Pain assessment report is rarely given It seems easy to OD kids


Evidenced interventions :Evidenced interventions Protocol liberalization Pointer et al. PEC 2005 Online to offline administration of morphine 2.8% to 19% increase in MS administration Education French et al. PEC 2005 3 hour educational intervention Pain med use 20.4% to 24.5% NP intervention 2.5% to 34.7% Pain scores 44.5% to 95.4%


Milwaukee Prehospital Pain Management Group :Milwaukee Prehospital Pain Management Group ‘Impact of an educational module on prehospital pain management in children’ Targeted Issue Grant by EMSC 2004-2007 PAMPPER (Pain Assessment and Management for Prehospital Pediatric EmeRgencies)


Reference Case :Reference Case Consider following issues during the presentation Q1: Why is prehospital pain management important? Q2: Initial assessment and intervention? Q3: Best method of pain assessment? Q4: Indications for pain management? Q5: What determines the need for pain medications? Q6: What medications should be considered? Q7: Dose and route of administration?


Negative Effects of Untreated Pain :Negative Effects of Untreated Pain Interferes with normal bodily function Increased metabolic rate Interferes with clotting Alters immune function Emotional stress/Suffering Anxiety (Fear of unknown) Powerlessness Loss of control Q1: Why is prehospital pain management important?


Pain results in a stress response :Biochemical: stress hormone release Epinephrine and norepinephrine Steroids, growth hormone, and glucagon Increase metabolic rate May cause cardiopulmonary instability Physiologic Tachycardia, tachypnea, BP elevation Behavioral Facial grimace Physical withdraw, kicking Crying The response varies in every patient based on age, development, and prior experience Pain results in a stress response


Pain results in a stress response :Biochemical: stress hormone release Epinephrine and norepinephrine Steroids, growth hormone, and glucagon Increase metabolic rate May cause cardiopulmonary instability Physiologic Tachycardia, tachypnea, BP elevation Behavioral Facial grimace Physical withdraw, kicking Crying The response varies in every patient based on age, development, and prior experience Pain results in a stress response


Pain results in a stress response :Biochemical: stress hormone release Epinephrine and norepinephrine Steroids, growth hormone, and glucagon Increase metabolic rate May cause cardiopulmonary instability Physiologic Tachycardia, tachypnea, BP elevation Behavioral Facial grimace Physical withdraw, kicking Crying The response varies in every patient based on age, development, and prior experience Pain results in a stress response


Pain results in a stress response :Biochemical: stress hormone release Epinephrine and norepinephrine Steroids, growth hormone, and glucagon Increase metabolic rate May cause cardiopulmonary instability Physiologic Tachycardia, tachypnea, BP elevation Behavioral Facial grimace Physical withdraw, kicking Crying The response varies in every patient based on age, development, and prior experience Pain results in a stress response


The evidence: Opioids decreases the stress response :The evidence: Opioids decreases the stress response Pain and its effects in the human neonate and fetus. Anand KJ. NEJM. 1987;317(21):1321-9. A landmark publication that called into question the widely held belief that neonates do not have the neurophysiologic apparatus to experience pain Also decreased stress response and decrease morbidity and mortality after major surgery in neonates. Neonatal and pediatric stress responses to anesthesia and operation. Anand KJ. Int Anes Clin. 1988 ;26(3):218-25. Benefit seen beyond neonatal period


The evidence: Effect of single painful procedure :The evidence: Effect of single painful procedure Effect of neonatal circumcision on pain response during subsequent routine vaccination. Taddio et al. Lancet. 1997:349(9052);599-603. No pain management during circumcision results in increased pain response at 4-6 months later Consequences of inadequate analgesia during painful procedures in children. Weisman et al. Arch Ped Adolesc Med 1998 Inadequate pain management during spinal tap results in increased pain scores during subsequent procedures Q1: Why is prehospital pain management important?


Why is prehospital pain management important? :Why is prehospital pain management important? Decreases pain and suffering Provides comfort during transport Expedites evaluation and interventions in the emergency Department May improve outcome


Most appropriate pain scale for 4 to 16 years :Most appropriate pain scale for 4 to 16 years Faces Pain Scale -Revised The Faces Pain Scale - Revised: Hicks CL et al.Pain 2001;93:173-183. Validated in children“true representation of pain” “These faces show how much something can hurt. This face (point to the left-most face) shows no pain. The faces show more and more pain (point left to right) up to this one (point to right –most face) it shows very much pain. Point to the face that show how much you hurt now.” 0 2 4 6 8 10 Q3: Best method of pain assessment?


Pre-hospital Pain Interventions :Pre-hospital Pain Interventions ABCDEs first Nonpharmacologic Pharmacologic Q4: Interventions for pain?


Non-Pharmacologic Pain InterventionsInjury specific :Non-Pharmacologic Pain InterventionsInjury specific Rest Ice Compression Elevate Splinting Dressing Positioning Q4: Interventions for pain?


Non Pharmacologic Pain InterventionsFear and Anxiety reduction :Non Pharmacologic Pain InterventionsFear and Anxiety reduction Q4: Interventions for pain?


When non-pharmacologic interventions are not enough? :When non-pharmacologic interventions are not enough? Reassessment of pain Pharmacologic intervention Continued moderate to severe pain (score ? 4) morphine sulfate Q4: Intervention for pain? Q5: What determines the need for pain meds? Q6: What meds should be considered?


Pharmacologic interventions :Pharmacologic interventions Morphine Gold standard IM/IV/SQ Fentanyl Less hemodynamic effects IM/IV/IN


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


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


Issues :Issues Head injury Unable to obtain vital signs Prolonged transport morphine versus fentanyl routes of administration Role of accepting MD/medical control Level of transport service Factors for additional doses


Emergency Department events: Patient with a fracture :Emergency Department events: Patient with a fracture Without prehospital pain management Initial evaluation by nurse and physician IV start Pain meds Radiograph With prehospital pain management Initial evaluation by nurse and physician Radiograph These 2 steps can be eliminated if patient’s pain is adequately controlled Manipulation of extremity for x-ray is Painful Q1: Why is prehospital pain management important? * ED staff may not be able to evaluate patient immediately!!!


Why is prehospital pain management important? :Why is prehospital pain management important?


Implications for the ED :Implications for the ED Awareness of the EMS protocols Confidence in EMS providers Voice in your EMS system Patient advocacy Continuum of pain management


Overview :Overview Prehospital pain management is important and needs improvement. EMS providers need expertise of ED providers ED providers must know the EMD protocols Pain management is a continuum


“To cure sometimes, to relieve often, to comfort always” :“To cure sometimes, to relieve often, to comfort always” 15th century French description of role of physician