Pain Management
Approach to pain in the paediatric burns patient
Adapted from Red Cross Hospital Burn Protocol (although these guidelines were developed and are intended for burns patients, they may also be of use in managing paediatric pain from multiple causes).
Objectives for analgesia and sedation
Requirements for procedures
EMLA topical analgesia
Objectives for analgesia and sedation
- To ensure control of pain, anxiety and movement
- Enhance safety
- Minimise patients psychological response: analgesia or anxiolytic with or without amnesia
- To have a sense of control over the situation and during the procedure
- To return patient to suitable state for safe discharge = pain under control or pain free
Requirements for procedures (DECIDE WHAT YOU NEED FOR THE PROCEDURE)
- Analgesia,
- Amnesia,
- Sedation,
- Anxiolysis
- Or combination of the above
Avoid IM injections in children at all cost as it is traumatic & increases anxiety
All the drug dosages are calculated according to the child’s body weight.
EMLA topical analgesia
- Topical application: EMLA 5%
- This is a eutectic mixture of lidocaine 25mg and prilocaine 25mg = 5g cream provides dermal analgesia by the release of lidocaine and prilocaine from the cream into the epidermal and dermal layers of the skin.
- Useful to prevent pain for IV catheter placement, when time and urgency allows.
- How to use EMLA:
- Apply little EMLA on the skin where you intend to put up a drip
- Cover with a clear adhesive dressing for 20 minutes up to 1 hour for effective analgesia
- Remove adhesive dressing, wipe away cream and site IV
Note: *Burnshield - meleleuca hydrogel provide analgesia and decrease burn injury
STEP 1
| DRUG | DOSAGE | FREQUENCY | SIDE EFFECTS | COMMENTS |
PARACETAMOL Paracetamol to be co-administered with either valoron drops or morphine | Oral: Loading dose: 20 mg/kg Maintenance: 15mg/kg Rectal: Loading dose 40mg/kg Maintenance: 30mg/kg Maximum daily dose:
Intravenously (Perfalgan) 15mg/kg/dose | Oral: 4-6 hourly Rectal: 8 hourly Intravenously: 6 hourly | Overdose causes liver failure |
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Warning: Patients with liver conditions: Paracetamol oral dose: 7.5 mg/kg/dose
STEP 2
| DRUG | DOSAGE | FREQUENCY | SIDE EFFECTS | COMMENTS |
| TILIDINE HCL (VALORON) | Oral /Sublingual: 0.5-1mg/kg | 6 hourly | As for Opioids
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STEP 3
DRUG | DOSAGE | FREQUENCY | SIDE EFFECTS | COMMENTS |
| MORPHINE | Oral: 0,3mg/kg/dose IVI: Bolus: 25 –100 mcg/kg/dose Infusion: 5- 40mcg/kg/hr | Oral: 8-12hrly IVI: Bolus: 4 hourly Infusion: continuous infusion |
| For severe burns, hypovolaemia or hypotension: do not use IM or sc. Give 0.025 – 0.05mg/kg by slow IV bolus. If no IV line, use valoron, 0.5mg/kg/dose po. Recovery of volume status may cause large doses sub-cut or intramuscular to reach circulation |
| KETAMINE | Analgesic doses Oral: 4-6mg/kg/dose IV: 0.25-0.5mg/kg/dose Infusion: 0.25-0.5 mg/kg/hour | Repeat dose prn to effect usually min 40-60 min) continuous | Salivation: (use atropine to reduce secretions: atropine dose 0.01-0.03 mg/kg/dose max. of 2.5mg) | Best used with midazolam (same route as ketamine) No hallucinations at this dose. |
NOTE: Opioid antagonist in case of inadvertent overdose of opioids (Reversal of pain relief). Naloxone (Narcan) 2-4 mcg/kg: IV/sub-cut/IMI (max 10 mcg/kg/dose)