Pediatric pain management

Physiologic manifestations of pain- peds
Tachycardia, tachypnea, hypertension, pupil dilation, pallor, increased perspiration, secretion of catecholamines, and adrenocorticoid hormones
Behavioral manifestations of pain- peds
short attention span, irritability, facial grimacing, biting or pursing lips, protecting the painful area, drawing up knees, lethargic, withdrawn, sleep disturbances
Facial manifestations of pain
bulged brow, brows lowered and drawn together, eyes squeezed shut, furrowed nasolabial creases, taut tongue, quivering chin
Developmental considerations in preschoolers
say “ow” and push away, uncooperative behavior, may cling to parent, blame someone for the pain
School age and older
Can use units of measure for pain, show where they hurt, remember to allow a sense of control and involve the child.
LMNOPQRS
Location, meaning, nature, onset, palliative/provacative, quality, radiation, severity, timing
Neonate pain assessment tool
NIPS
Infant pain assessment tool
FLACC (Face, legs, Activity, Cry, Consolability) or MIPS
Preschoolers pain scale of choice
Wong-Baker Faces Scale
Age at which child can begin to describe pain in more detail and give its location
age 8
Should opioid pain medication be PRN or scheduled with children? Why?
Should be scheduled to reduce possibility of break through pain
Should pain control be provided for minor procedures in pediatrics?
It should, because anxiety and distress are caused by the anticipation of the event. Previous experience with painful procedures increases anticipatory pain.
What are some local anesthetics they can use for minor procedures?
EMLA (60 mins prior), EMLA max (30 mins), vapocoolant sprays (immediate), Intradermal lidocaine (less than a min, but needs to be buffered with bicarb)
For major procedures, what is the most helpful way to manage pain?
Sedation with analgesia and anxiolysis. Amnesia is debatable in it’s helpfulness.
Drugs used in pediatric sedation
Valium, versed, ativan are benzos. Hypnotics/barbituates (thiopental, pentobarbital), ketamine, propofol, fentanyl.
Age of skeletal maturation
20 years. Epiphyses are cartilaginous until then, CA++ needed for new bone growth.
What can happen if the epiphyseal plate is damaged?
It can affect future growth
What is the etiology of kyphosis/lordosis?
Inability of the spine to change in response to growth
When is the muscular system completely formed?
At birth
What is a sprain?
A torn ligament, caused by twisting or trauma to a joint
What is metatarsus adductus?
most common congenital foot disorder. It is when the forefoot turns inward.
What is clubfoot?
a congenital anomaly where the foot is twisted. It involves muscles, bones and tendons.
What is the treatment for clubfoot?
Cannot be corrected by exercise, serial casting if done early. Surgical correction can be done between 3 and 12 mos. of age.
Genu Varum
bowlegged
Genu Valgum
knock knees
When do we start to worry about knock knees and bowleggedness?
At around 4-5 years of age when they will need either braces or surgery to correct
Describe developmental dysplasia of the hip
It is when the head of the femur and the acetabulum are not aligned properly. It is most commonly unilateral. Use a pavlik harness under 3 mos. Use skin traction after 3 mos. Use a spica cast when they are older than 18 mos.
What is slipped capital femoral epiphysis?
Femoral head displaced from femoral neck. This occurs during the adolescent growth spurt. The cause is unknown but it is likely that it is caused by obesity and endocrine disorders. Treatment is surgical, and dietary to address the obesity.
Define scoliosis
Lateral S or C shaped curvature of the spine. More than 10 degrees is abnormal. 3 types are idiopathic, congenital and acquired. Tx: observation and serial x-rays. then brace, then spinal fusion if necessary
Osteomyelitis
Infection of the bone, usually in the lower long bones. Sx: pain, swelling, decreased mobility, fever. Tx: antimicrobials for 3-6 weeks. Check immunization for tetanus, obtain cultures and blood work and admin fluids and meds.
Marfan syndrome
genetic condition that affects the connective tissue. Common serious problems, mitral valve prolapse, aortic regurgitation and abnormal aortic root dimensions.
Muscular dystrophy
Group of inherited diseases. Duchenne most common. Terminal. No specific treatment, just try and preserve muscle function and prevent complications.
Care of a child in a cast.
Elevation, check for drainage, bleeding, neurovascular checks, itching
Care of a child in a brace
Brace should be comfortable. Skin care is paramount issue. Wear clothes beneath brace.
Compartment syndrome
Medical emergency, caused by swelling stretching against fascia creating a closed space. Causes ischemia and cell death. Treatment is incision of fascia to relieve pressure