Pediatric emergency medicine trisk 1068

opiate medications, while the COMT V158M variant has been associated with decreased need for pain medication The context of an injury also plays a role; children who are hit during play may not complain of pain, yet may experience pain if the injury was meant as an attack or as punishment A child’s past experience with painful stimuli is also important One study showed that inadequate analgesia for one painful procedure might diminish the effect of adequate analgesia in subsequent procedures Of course, the painful stimulus itself is important, and a stimulus that causes a great deal of tissue damage may hurt more than one that causes minor injury Figure 129.1 summarizes the components of a pediatric patient’s pain experience Uncontrolled pain may lead to hyperalgesia, a state where the painful stimulus causes more pain than normally expected Infants who undergo a painful experience develop an altered response to future episodes of pain For instance, infants circumcised without anesthesia show increased distress during routine immunizations at to months of age, compared with those who received topical local anesthetic at the time of circumcision This has also been demonstrated in neonates who had repeated heel sticks Furthermore, surveys of patients, parents, and families show that satisfaction with the ED experience is highly dependent on the degree of pain a patient experiences and the efforts made to alleviate the pain One study demonstrated that more than 75% of caregivers would be willing to pay $15 and more than one-third would pay $100 to make an intravenous (IV) cannulation procedure painless The Joint Commission has specific guidelines stating that patients have the right to pain assessment and treatment This pain must be frequently reassessed, and appropriately addressed with adequate analgesia FIGURE 129.1 Components of pain (Adapted from Schecter NL Pain and pain control in children Curr Probl Pediatr Adolesc Health Care 1985;15:4–67 Copyright © 1985 Elsevier With permission.) Realistically, pain in the pediatric patient who presents to the ED may never be eliminated completely Efforts must be made, however, to relieve pain as much as possible and strive toward the “ouchless” ED ( Table 129.1 ) Assessment of Pain in Children The Joint Commission requires screening for pain and periodic reassessment The clinical evaluation of pain may be accomplished through physiologic measurements, behavioral assessment, or self-report Infants and preschool children (younger than years of age) cannot understand the nature of self-report scales, and their assessment, therefore, relies on observer report Physiologic indicators of pain include heart and respiratory rates, blood pressure, and palm sweating Of interest, but not yet of practical use in the emergency setting, is the correlation between an individual’s pain and the acutely measured levels of stress hormones, such as cortisol, catecholamines, and glucagon Observational behavioral pain assessments can, however, measure markers of behavioral distress experienced by the child and noted by caregivers These include facial expression, verbal expression, and positioning Examples of behavioral pain scales are the Behavioral Pain Score and the Children’s Hospital of Eastern Ontario Pain Scale Some observational pain scales use a combination of behavioral and physiologic measurements Examples of such combination scales unique to neonatal population are the Neonatal Infant Pain Scale, Neonatal Pain Agitation and Sedation Scale, and the Pain Assessment Tool TABLE 129.1 POSSIBLE REASONS FOR INADEQUATE PAIN CONTROL IN EMERGENCY DEPARTMENT Inability of young children to talk Misconception that infants cannot feel pain Misconception that children will not remember pain Misconception that children will get addicted to opioids Fear of respiratory depression and hypotension Unfamiliarity with analgesics and dosages Other conditions taking priority Self-report pain scales are the best indicators of pain and are the reference standard for assessing pain in children Standard self-report assessment tools, such as visual analog scales (VASs), are more reliable indicators of pain when completed by the patient rather than by observers Young children (between ages and years) can reliably use picture scales with faces in different phases of happiness and crying The Wong–Baker FACES Pain Rating Scale ( Fig 129.2 ) is one example of this type of ordinal scale For older children and adults, a VAS consists of a 10-cm horizontal line with end points marked as “no pain” (0) to “worst possible pain” (10) The VAS has been further enhanced for children by allowing them to use multiple modalities for pain rating such as allowing the child to determine changes in height, thickness, and color as the pain intensity increases, and to capitalize on the child’s ability to discriminate his or her pain using at least one of these dimensions ... Health Care 1985;15:4–67 Copyright © 1985 Elsevier With permission.) Realistically, pain in the pediatric patient who presents to the ED may never be eliminated completely Efforts must be made,... respiratory rates, blood pressure, and palm sweating Of interest, but not yet of practical use in the emergency setting, is the correlation between an individual’s pain and the acutely measured levels... Scale, and the Pain Assessment Tool TABLE 129.1 POSSIBLE REASONS FOR INADEQUATE PAIN CONTROL IN EMERGENCY DEPARTMENT Inability of young children to talk Misconception that infants cannot feel