You’re in the rapid response vehicle, having just handed over a 2 year old with a femoral fracture. As you clear the hospital, a call comes in: 8 year old, fall from slide, deformed left arm, conscious and breathing. When you arrive in the house you find him lying on the sofa, with bruising and deformity of his left elbow. The paracetamol and ibuprofen given by his mother has not controlled his pain*, so you take out a methoxyflurane inhaler and explain to him to suck in and blow out through ‘the whistle’. After a few breaths he begins to relax.
Methoxyflurane is a fluorinated hydrocarbon, used as an inhaled anaesthetic in the ’60s and early ’70s, until it fell out of favour after case reports describing renal failure at anaesthetic doses. But, when given in small doses, methoxyflurane has excellent analgesic properties, with no nephrotoxic side effects. It has been used extensively in Australia and New Zealand by prehospital clinicians as a self-administered analgesic for short-term pain relief in adults and children. After being licenced in 2015 in the UK and Ireland for the emergency relief of moderate to severe pain in conscious adults with trauma, methoxyflurane was included in the Irish prehospital CPG for EMTs, paramedics and advanced paramedics with permission under the seventh amendment to allow its use in children.
Added as a liquid to a Penthrox® inhaler, methoxyflurane vaporises, to be inhaled on demand. It has revolutionised prehospital pain control due to its quick onset and easy, pain free administration and, because of its light weight, crews can carry it over rough ground easily. Known as ‘the green whistle‘, each 3ml dose is quoted to last between 20 and 30 minutes, but in practice can sometimes last up to 45 minutes or an hour, depending on a child’s respiratory rate and depth and the way in which they self-administer. The Irish prehospital CPGs allow two inhalers to be administered in 24 hours to a patient, so when there’s an extended journey time, methoxyflurane inhalers used back-to-back can provide up to two hours of analgesia, which can be supplemented by the simple analgesics, paracetamol and ibuprofen, or morphine, fentanyl and ketamine, as needed.
But what’s the evidence for methoxyflurane in children?
Pop methoxyflurane in the PubMed search bar, and a lot comes up. It’s safe, it works, but there are surprisingly few randomised controlled trials (RCTs) that include children. A couple of observational studies are noteworthy. An Australian study in the prehospital setting, published in 2006 by Franz Babl and colleagues, describes an observational case series of 105 children, ranging in age from 15 months to 17 years, who received methoxyflurane while by being conveyed to hospital by ambulance. The children’s pain scores dropped from 7.9 to 4.5, with few side effects, although there was a tendency towards deep sedation in the under 5s. The following year Babl’s team published an ED-based observational case series of 14 children aged 6 to 13 years with extremity injuries who received methoxyflurane for painful procedures in the hospital setting. Although methoxyflurane was a useful analgesic agent, Babl’s team found it did not work as well as a procedural analgesic for fracture reduction.
The first double-blind RCT of methoxyflurane in children was published almost two decades ago by Chin et al in 2002. Forty-one children over the age of 5 with upper limb fractures were randomised to receive either methoxyflurane or placebo. Unsurprisingly, methoxyflurane resulted in a lower pain score at 10 minutes than placebo. Adverse events weren’t reported, but the apparent safety and efficacy of methoxyflurane demonstrated in this study paved the way the some bigger and better RCTs.
A better known, and more recent, RCT involving children was the STOP! trial, published in the EMJ in 2014. This randomised, double-blind placebo-controlled trial was conducted at six EDs in the UK. Three hundred patients, 90 between the ages of 12 and 17, with minor trauma (such as burns, fractures, dislocations and lacerations), were randomised to receive either methoxyflurane or saline via an inhaler. In a nifty way to keep the patients, doctors and nurses blinded to which drug was being administered, a drop of methoxyflurane was added to the outside of every inhaler so both drug devices smelled the same. Pain scores dropped significantly lower in the methoxyflurane group, with a median onset of action of 4 minutes. But what about those adolescents? Although 45 12 to 17 year olds were included in each group, their data wasn’t analysed separately, and children under the age of 12 were excluded from the study, so although we can probably assume methoxyflurane works well and is safe in adolescents, more trials would be helpful.
Segue to the Magpie trial, which is currently recruiting in the UK and Ireland via the PERUKI network. This international multi-centre randomised, double-blind placebo-controlled trial is specifically investigating the efficacy and safety of methoxyflurane in children and young people so that its UK license can be extended to include children. Like STOP!, participants are being randomised to either methoxyflurane or placebo (again saline) via an inhaler. To ensure younger children are well represented in the study data, the study team are aiming to recruit higher numbers of 6 to 11 year olds than adolescents, with a recruitment target of 220 children and adolescents in total. We’re awaiting the results eagerly…
*A top tip on top up dosing
This child had been given 500mg of paracetamol and 280mg of ibuprofen by his mother before the crew arrived. He was 8 years old, with an estimated weight of 31kg. Based on Irish CPGs allowing a paracetamol dose of 20mg/kg (620mg) and ibuprofen dose of 10mg/kg (310mg) he was underdosed. It’s important to top-up simple analgesics as part of your approach to pain relief in children.
But what happened to the 8 year old?
You check CSMs (circulation, sensation and movement) before and after applying a splint and transfer him to the ambulance on a stretcher. His pain is very well controlled, and he asks his mother to take a photo for his friends. This sentence is hard for him to say and he gets the giggles. You transfer him uneventfully to hospital where he’s diagnosed with a supracondylar fracture.
Hartshorn, S., & Middleton, P. M. (2019). Efficacy and safety of inhaled low-dose methoxyflurane for acute paediatric pain: A systematic review. Trauma, 21(2), 94–102. https://doi.org/10.1177/1460408618798391
Babl FE, Jamison SR, Spicer M, Bernard S. Inhaled methoxyflurane as a prehospital analgesic in children. Emerg Med Australas. 2006;18(4):404-410. doi:10.1111/j.1742-6723.2006.00874.x
Babl FE, Barnett P, Palmer G, Oakley E and Davidson A. A pilot study of inhaled methoxyflurane for procedural analgesia in children. Pediatric Anesthesia. 2007;17:148-153. doi:10.1111/j.1460-9592.2006.02037.x
Chin, R, McCaskill, M, Browne, G A randomized controlled trial of inhaled methoxyflurance pain relief in children with upper limb fracture. J Paediatr Child Health 2002; 38: A13–A13.
Hartshorn, S., Barrett, M.J., Lyttle, M.D. et al. Inhaled methoxyflurane (Penthrox®) versus placebo for injury-associated analgesia in children—the MAGPIE trial (MEOF-002): study protocol for a randomised controlled trial. Trials 20, 393 (2019). https://doi.org/10.1186/s13063-019-3511-4
Jamie is a 3-year-old boy who presents to the emergency department. He was playing with his 5-year-old brother on the trampoline and fell off. He is very distressed and crying in triage but his mum doesn’t know where he hurt himself. She had rushed to the department with him and so hadn’t given him any prehospital analgesia. Mum herself also appears very anxious and worried.
Pain assessment and management in the paediatric population is a challenging area, and it is something that we often get wrong. Children’s pain is historically poorly measured and often undertreated because children may not exhibit the common signs and symptoms of pain that we come to expect from adults.
Pain is multifactorial. In children, it is important to not just focus on the injury but the age and developmental stage of the child, the circumstances of the presentation to ED, the behavior of the parent/caregiver and the child’s interaction with them.
In the case of James, his mum appears very anxious about his injury. Children tend to feed off of their parent’s anxiety and become more distressed. Moving them to a quiet area for assessment and reassuring mum that they are in the right place and that you’re going to take great care of James is an ideal starting point. Hopefully, reassuring and calming his mum will go some way to diffusing the situation, and calming James also.
Assessment of a child in pain varies greatly with their age and developmental stage. This is one of the most important things to take into account during your encounter. If the wrong tool is used, the pain may be underestimated and the child under-treated. The longer the time to proper pain relief, the more distress there is for both child and parent, and so the spiral continues.
Neonates and infants (0 – 2 years)
For the youngest, the FLACC (Faces, Legs, Arms, Cry, Consolability) scale can be useful. This scale comprises of five components. The child needs to be observed for at least a minute. A child of this age isn’t going to be able to tell you much about their pain, so you need to rely heavily on your observational skills. Involving the parent in the assessment is key.
Context is very important in this group also, particularly for the one-year-old who seems very distressed in triage or when being examined by the strange doctor but is more settled in mum’s lap. Frequent reassessments are therefore extremely important and beneficial.
Toddlers and preschoolers (2 – 4 years)
In this group, developing a rapport is a must in order to be able to accurately assess the level of pain. Get on the child’s level, use a soothing friendly voice, employ some ice-breaking chat.
Ask open-ended questions, don’t just palpate areas and say “Does this hurt?” – as you may well get a yes in every area – e.g. “Can you show me where is sore? Can you point to what is hurting you?”
For these slightly older children, the Wong-Baker faces scale is great. These can be produced in bright colours to make them fun and to aid with their participation in the assessment.
This scale has been validated in children aged 3 and up, but in practice it is often used in those over 2. The child is shown the faces and asked to point to the one that best represents how they are feeling.
Again, reassessment after initial analgesia using the same scale/method of assessment is important.
School-aged children (4 – 16 years)
As the child develops verbally, the assessment of their pain should become easier. For children aged 4-8 years of age, the Wong-Baker faces scale is probably still the most appropriate tool to use. In the older child, you can use the numerical pain ladder.
This can be either a visual representation where you ask them to draw a line or indicate where their pain falls on a physical scale, or you can simply ask them to give their pain a score out of 10 without showing them the scale.
You move James and his mum to the minors area to complete his assessment. Mum is now calmer, and this seems to have settled James somewhat. He is no longer crying, but he is still grimacing and he appears to be holding his left elbow fixed in flexion. You ask him point to where it is sore and he indicates his left arm. He refuses to move it. A survey of the rest of his body doesn’t reveal anything else concerning, he is fully weight-bearing and is moving his neck and right arm without issue. On palpation and careful examination of the left arm he is very distressed when his elbow is touched, and it appears to be swollen. You show him the Wong-Baker scale and he points to the orange sad face, which indicates a pain score of 8.
To achieve the best pain management for our patients, we first have to have a basic grasp of pain physiology.
Nocioceptive pain follows a sequence where 4 events take place:
Pain transduction – a painful stimulus eg trauma causes tissue damage – this leads to the release of chemical mediators in the tissue, e.g. prostaglandins/substance P etc. These trigger an action potential.
Transmission – the action potential moves along the nerve fibres, travelling from the peripheral site of injury to the spinal cord.
Perception – the action potential travels along the spinothalamic tract to the brain, where it is relayed to the areas involved in pain perception (limbic system, somatosensory cortex, parietal and frontal lobes)
Modulation – the midbrain releases endorphins/serotonin etc to mitigate pain
We can target each part of the sequence in our treatment of pain, as long as we remember that analgesia is multi-modal, and does not just revolve around drugs.
We can intervene at this stage by employing basic first aid measures – for example
If a limb is obviously deformed or clinically has a fracture – splint or backslab the limb during your initial assessment and before sending the child for x-rays
If there is a suspicion of a clavicular or shoulder injury give the child a sling
If they have a swollen area ?soft tissue injury e.g. ankle – place an ice pack and get them to elevate the ankle.
These things may seem like common sense, but all too often they are forgotten in favour of pharmacological interventions which will not have as immediate an effect.
A child can be distracted much more easily than an adult, and we need to use this to our advantage in the context of pain management. Employing distraction techniques can affect and reduce a child’s perception of pain.
There are many options available and you can get the parents involved also. Distraction techniques obviously vary in their effectiveness depending on the age of the child, but they include: story-telling; singing a song (I can’t be the only one that hears Baby Shark as they fall asleep at this point!); balloons; stickers; bubbles; playing a video on a smartphone.
For older children, guided imagination can be used to great effect, particularly before procedural sedation with nitrous oxide or ketamine. Letting them listen to their own music on their phone via earphones is also a good idea. Some departments are now looking at the role of virtual reality headsets for older children undergoing painful procedures which appears to be a very successful method of distraction.
Pharmacological agents act to interrupt the transmission of the painful stimulus. There are many agents available, depending on the child’s age and the level of pain described.
Ametop (4% w/w Tetracaine) and EMLA 5% (lidocaine/prilocaine) are anaesthetic creams that can be applied to intact skin, usually pre-cannulation. They numb the skin and make the procedure less painful. They are ideal in situations where a slight delay to cannulation is safe, as they need to be in situ for a while to work (Ametop 30 mins, EMLA for an hour).
LAT gel – Lignocaine 4% / Tetracaine 0.5% / Adrenaline 0.1% is an anaesthetic gel. It comes in a single-use bottle. It is designed for use on broken skin, and so it should be ideally applied to wounds/lacerations in triage and left in situ for 30. It numbs the area and allows for thorough cleaning, proper assessment, and closure of wounds while reducing the need for injectable local anaesthetic in a lot of cases.
ANY previous reaction to local/ general anaesthetic or known cholinesterase deficiency
Wound on or near mucus membrane including eye, nose or mouth.
Wound > 5 cm in length
Concern about tissue viability i.e. crush or flap wounds
Wounds over 8 hours old
Obvious injury to associated structures i.e. bone, tendon, blood vessels, joint or nerve
Wounds to the ear, nose, genitalia or digits should be discussed with a registrar before using LAT gel. This is due to concerns about perfusion and also due to evidence showing less effect on extremity wounds.
This is perhaps best known to parents as Calpol (UK and Ireland), Panadol or Crocin (Australia) or Tylenol (in the States), however, there are other brand names. There are two different preparations of Calpol depending on age (120mg/ 5mls or 250mg/5mls) so make sure to clarify what the parent has at home.
Paracetamol can be given PO/PR/IV but is most commonly given orally. The dose is 15mg/kg to a maximum dose of 1 g.
It can be given 4-6 hourly, but to a maximum of 4 doses in 24 hours. It takes approximately 30 minutes to work
Overdose is 75mg/kg (although toxicity usually doesn’t occur until >150mg/kg in an acute ingestion or repeated supra therapeutic doses>100mg/kg). If this happens it can cause hepatic necrosis – so bloods will need to be checked and if the paracetamol level is beyond a certain threshold the child will need to be started on n-acetyl cysteine.
Ibuprofen is a non-steroidal anti-inflammatory (NSAID) that is available over the counter. NSAIDs work to stop the inflammatory cascade of chemical mediators and thus reduce inflammation and pain. It is also an anti-pyretic.
It is commonly sold as Nurofen (in the UK, Ireland and Australia) and Advil (in America) but again has other brand names as well as being sold by generic name. Nurofen also comes in two preparations (100mg/5mls or 200mg/5mls) – always clarify with the parents as to what they have at home to ensure appropriate dosing.
Ibuprofen can be given at a dose of 10mg/kg to a max of 400mg 8 hourly. An overdose obviously isn’t desirable but does not carry the same dangers as paracetamol.
It can be given PO or PR, however the suppositories only come in 60mg so are not as useful in bigger children.
Always, always double-check which medicine a parent may have given at home. For example, Calpol contains paracetamol but Calprofen contains ibuprofen – you can see how double doses can accidentally be given in the emergency department soon after a child presents.
Diclofenac also a member of the NSAID family. It can be used in place of ibuprofen in the older child in its oral form.
In my own practice PR diclofenac suppositories have been invaluable in the pain management of infants with stomatitis or bad tonsillitis causing distress and poor oral intake, while also controlling their pyrexia.
The dose is 1mg/kg 8 hourly (max 50mg per dose) and can be given PO/PR.
Max dose is 3mg/kg in 24 hours.
Morphine is a strong natural opioid. It is used for severe pain, or pain that is not responding to first-line analgesics. It can be given by a variety of routes, but most commonly PO or IV.
Oramorph is an oral form of morphine, available in liquid preparation and is dosed by age band:
<1 year: 80 -200mcg/kg
12-18 years: 10-15mg
Its IV dose is 0.1mg/kg. It can be given prn usually every 4-6 hours
Potentially serious side effects include decreased respiratory effort and low blood pressure. Overdose treatment includes the administration of naloxone (0.1mg/kg IM or IV).
Fentanyl is a strong synthetic opioid with a faster onset / offset than morphine, starts to work within 7 minutes. It’s great for initial analgesia for fractures/dislocations, burns, major lacerations.
The loading dose is 1.5mcg/kg and can be repeated after 20-30 minutes
Side effects are uncommon, but may include respiratory depression/hypotension/nausea and vomiting. It is given intranasally (IN) with an atomizer device and has great mucosal uptake without having the need for IV access.
Diamorphine is also an opioid that can be given intranasally as an alternative to fentanyl, using an atomizer device.
The dose is 0.1mg/kg IN
It carries the same potential side effects as morphine and fentanyl, but has been shown to be very safe at this dose in the paediatric population.
Methyoxyflurane is also known as Penthrox / the green whistleIt is an inhaled medication primarily used to improve pain following trauma. Each dose lasts approximately 30 minutes.
Pain relief begins after 6–8 breaths and continues for several minutes after stopping inhalation
It is self-administered to children and adults using a hand-held inhaler device
The STOP trial looked at its safety and efficacy in adults and children >12 and found that it was safe and worked well. It is currently being investigated in those aged 6-18 in the MAGPIE trial, which is still undergoing data collection.
Sometimes, analgesia alone isn’t enough. If a child has a deformed fracture for example that needs to be manipulated, they will need procedural sedation. This is usually achieved with wither nitrous oxide or ketamine, depending on the child’s age and the procedure required.
You suspect that Jamie has a fractured arm, perhaps a supracondylar fracture. His weight is 18kg. Given his level of distress and pain score of 8, you give him both IN fentanyl 27mcg and paracetamol 270mg. Mum plays a video on her phone for him while you apply an above elbow backslab to splint and immobilize his arm before he goes to x-ray.
You reassess him after these interventions and he looks much happier, you even get a smile. He indicates the second green face on the Wong-Baker scale, equating with a pain score of 2. He goes for an x-ray which confirms a supracondylar fracture – Gartland 2. You refer him to the orthopaedic team for admission and management. You ensure that he has regular analgesics as well as PRN extras written up in his drug Kardex before he leaves the department to go to the ward.
Srouji R, Ratnapalan S, Schneeweiss. Pain in Children: Assessment and Nonpharmacological Management. International Journal of Pediatrics. 2010. doi:10.1155/2010/474838
Sharif MR et al. Rectal Diclofenac Versus Rectal Paracetamol: Comparison of Antipyretic Effectiveness in Children. Iran Red Crescent Med J. 2016;18(1): e27932
Kendall J, Maconochie I, Wong ICK, et al; A novel multipatient intranasal diamorphine spray for use in acute pain in children: pharmacovigilance data from an observational study. Emerg Med J 2015;32:269-273.
Coffey F, Wright J, Hartshorn S, et al: STOP!: a randomised, double-blind, placebo-controlled study of the efficacy and safety of methoxyflurane for the treatment of acute pain. Emerg Med J 2014;31:613-618.
FLACC (Face, legs, activity, cry, and consolability)
Wong Baker Faces
Visual analogue scale
See the analgesic ladder (RCEM guidance above and the WHO pain ladder).
Adjuvants should be considered in all steps of the ladder.
Bottom of the ladder is the most commonly used paracetamol (at 15mg/kg/dose) and non-steroidal anti-inflammatory drugs (NSAIDs). Paracetamol is an antipyretic and weak analgesic. It is used for the treatment of mild pain and fever associated with a sore throat or illness. But we should avoid oligo-analgesia and use the right drug for the right kind of pain.
Moving up the ladder are weak opioids like codeine. Codeine (an inactive compound of morphine) is no longer recommended for the management of acute moderate pain, particularly in children under 12 years with obstructive sleep apnoea or for post tonsillectomy procedures. Codeine must be metabolised by the cytochrome P450 enzyme 2D6 to the active compound, morphine, to relieve pain. Poor metabolisers of codeine may metabolise only up to 15% of the morphine concentration, receiving little or no analgesia from codeine. Ultra rapid metabolisers may metabolise up to 50% more morphine than normal metabolisers – which is potentially life threatening.
Children with moderate to severe pain should receive opioids together with non opioids. Morphine, oxycodone, hydromorphone are all active compounds that do not require the enzyme conversion to provide analgesia. Fentanyl, a synthetic opioid, has few, if any cardiovascular side effects. This is in contrast to morphine which may exacerbate hypotension with its vasodilatory effects. So in haemodynamically unstable children, fentanyl may be the preferred choice for acute pain management.
What about IN fentanyl?
It’s easy to use, it’s needle-less, and decreases the overall need for utilisation of IV or IM routes which is a positive change in parent and patient satisfaction. It bypasses first pass metabolism permitting rapid and predictable bioavailability (compared with oral and intramuscular routes) and offers direct CSF delivery via the nose- brain pathway route
The maximum volume of IN medication permitted is 1ml per nostril and in cases of nasal trauma or septal defects, IN Fentanyl of course cannot be used. Rule of thumb, the IN dose is 2-3 times the IV dose.
Administer intranasal medications in the sniffing position. Lie the patient flat with occiput posterior, put patient in the sniffing position, seat the mucosal atomizing device cushion in the nostril, aim toward the pinna of the ear, and shoot fast – you have to push the drug as fast as you can to atomize the solution.
IN medication can be used for sedation, anxiolysis, pain control and seizure management. A 2014 Cochrane review on intranasal fentanyl concluded that it can be an effective analgesic for children aged 3 years and above with acute moderate to severe pain. Studies have demonstrated INF to result in decreased time to medication administration and equivalent pain control when compared to IV morphine, oral morphine or IV Fentanyl. IN Fentanyl (1.5mcg/kg) has become an excellent alternative to morphine in the ED, it has a greater safety profile and is easily available in the ED.
What about IN Ketamine?
How does it compare to IN Fentanyl? One study demonstrated a similar pain reduction in children with moderate to severe pain from an isolated limb injury in the Paediatric ED, although the sample size was small and there was no comparator or placebo group. Adverse effects were more frequent with ketamine; however, these were all relatively mild (drowsiness and dizziness). Also, practically speaking, pain control doses for the IN Ketamine route at 1mg/kg mean that volumes for most children weighing above 10kg will exceed 1ml per naris if the ketamine concentration 10mg/ml is used.
What about IN Dexmedetomidine?
An alpha-2 receptor agonist (like clonidine), does not markedly decrease blood pressure. Dexmedetomidine targets receptors in the CNS and spinal cord, and so it provides deep sedation, with very minimal blood pressure effects. It induces a sleep-like state. In fact, EEGs done under dex show the same pattern as seen in stage II sleep. Dexmedetomidine is safe, if titrated, and does not depress airway reflexes or respiration. Dose is 2.5 mcg/kg IN, and can add another 1 mcg/kg if needed. The downside is that it can last 30 minutes or more, but it may be a good choice for an abdominal ultrasound or CT head.Inflicting Pain with an IV to relieve pain is not something that makes sense to young children. IN medication offers pain relief prior to getting intravenous access and can even obviate the need for IV access if definitive care such as a cast, suturing, reduction of bony injuries can be done during the duration of action of the IN medication.
Consider non-pharmacological adjuncts
It is important these are thought about in conjunction with pharmacological techniques. These include: Play specialists
Don’t forget the Bubbles
Immobilisation of injuries
Sucrose, and non-nutritive sucking interventions exert analgesic effects independent of the opioid pathway. Swaddling/facilitated tucking (preterm) and skin to skin care significantly increase B-endorphin levels.
Rocking/holding neonates and breastfeeding during minor procedures have all been shown to decrease objective measures of pain such as heart rate and crying.
Pain should be assessed on arrival and then monitored throughout their time in the emergency department and if appropriate beyond. Children in moderate and severe pain should have their pain reassessed within 60 minutes of receiving analgesia.
Frank, 8-years-old, was playing in the street with friends and fell over. He cut his knee on some broken glass and sustained a 4 cm laceration over his patella. An x-ray shows no foreign body and no fractures. The knee is swollen and the laceration requires suturing. On pain assessment he is reporting mild pain.
What are your initial considerations?
What are the options for cleaning and closing?
Don’t forget oral analgesics (as above) and a full assessment for other injuries.
LAT gel (lidocaine, adrenaline and tetracaine)
Unsuitable for under 1s
Takes 20-30 minutes to work
Skin will blanch when ready
Max dose: 2 mls for 1 -3 year; 3 mls for >3 years
Not for use on: mucous membranes; extremities; wounds >8 hours old
Can be used in conjunction with local anaesthetic infiltration
Max dose not to exceed 5mg/kg
Local anaesthetic infiltration
Inject slowly to reduce pain
Small gauge needle to reduce pain
Doses: 3mg/kg lidocaine
Other topical agents (not for this case specifically):
EMLA cream (lidocaine 2.5% and prilocaine 2.5%) is effective at numbing the tissue below intact skin to a depth of 6-7mm if left on for 30-60 min but does cause vasoconstriction which can be problematic if looking to cannulate.
LMX4, a topical liposomal 4% lidocaine cream like EMLA has full effectiveness by 30 minutes.
Play specialist Distraction techniques appropriate to age
Preparation of the child and area
Using appropriate language
Freddie, 9 years old, attends the emergency department after falling from the monkey bars. He has sustained a displaced and angulated supracondylar fracture. He has some tingling at the fingers in the ulna distribution and therefore requires urgent manipulation.You decide to use nitrous oxide.
Do you need any pharmacological adjuncts?
What about non pharmacological?
What other considerations should be made?
Nitrous oxide – mechanism
Nitrous oxide provides anaesthesia, anoxiolysis and some mild amnesia but offers limited analgesia. Administration of analgesic supplements is recommended. Many papers including the FAN study demonstrate the safety and efficacy of co-administering intranasal fentanyl. Other analgesics can also be safely used.
There are two methods of delivering nitrous oxide, piped nitrous oxide and Entonox. Piped nitrous oxide can provide variable concentrations and can be titrated to response, whereas entonox is a fixed 50/50 mix of nitrous and oxygen and comes in canisters. The canister is set up with a demand value that needs to be overcome with a deep breath; this can be difficult for under 5’s. You should see onset of effect in 30-60 seconds with the peak effect at 2-5 minutes. Offset of effects is similar at 2-5minutes, 100% oxygen should be applied during this time post procedure to avoid diffusion hypoxia.
Side effects are minor and transient but include:
Vomiting (6-10% children receiving 50% dose). Increases incidence with higher dose, longer duration and concurrent opioid use. Consider prophylactic antiemetic if child has history of nausea or vomiting.
Nitrous oxide diffuses through tissues more rapidly than nitrogen alone and can expand in air containing spaces within the body, so it is contraindicated in:
Nitrous oxide inactivates the vitamin B12 dependent enzyme, methionine synthase and can deplete the B12 stores. Therefore caution is advised in those at risk of vitamin B12 deficiency (vegetarians, patients with gastrointestinal disorders and those taking regular H2 receptors and proton pump inhibitors)
Monitoring and staffing
Despite the absence of use of intravenous sedative drugs, it is best practice to manage this patient in a high dependency setting, with monitoring including; respiratory rate, heart rate and oxygen saturations and at least 2 members of staff where one’s job is entirely focused on the sedation and monitoring of the child.
Guided imagery would work well in this setting with a trained practitioner. This is a process where a variety of techniques can be used such as simple visualisation, story telling, direct suggestion imagery and fantasy exploration to elicit a physical response such as a reduction in pain, stress or anxiety.
Lola, 2 years old, has fallen in the playground and sustained a laceration to the forehead. Lola had an ice cream after the incident in an attempt to settle her. She has no past medical history and was born at term. Can she have procedural sedation in the department? What are the considerations?
What drugs do you need for the sedation? Should you use any adjuncts with the ketamine? Are there any emergency drugs you should have available?
There are no contraindications and you decide to go ahead with ketamine sedation, during the procedure whilst full monitoring in place the CO2 trace is lost. What is your structured approach to management of this scenario?
A through pre sedation assessment is required to assess ASA grade, examine airway anatomy and illicit any contraindications listed below
Multiple studies have shown that fasting does not reduce the risk of aspiration or increase the risk of adverse events and the 2020 updated guidelines for ketamine sedation in the ED have echoed this. They advised that the fasting state should be considered in relation to the urgency of the procedure, but recent food intake should not be considered a contraindication to ketamine use.
RCEM states the procedure should be carried out in an area with immediate access to full resuscitation facilities; three practitioners should be present throughout, one for the sedation, one for the procedure and one for monitoring and assistance. The updated 2020 guidance has included capnography in the mandatory monitoring required along with heart rate, ECG, blood pressure, respiratory rate and oxygen saturations. While there is no evidence that shows that capnography reduces the incidence of adverse events, there are studies that show capnography decreased the incidence of hypoxia and respiratory events.
Oxygen should be given prior to the procedure if possible and during to reduce the time to de-saturation should an adverse event occur.
Ketamine is a NMDA receptor antagonist. It is a dissociative anaesthetic, a potent analgesic and amnesic. Ketamine induces a trance like state, often with the eyes open. It maintains the airway reflexes and maintains cardiovascular stability.
The RCEM accepted dose is1mg/kg over 60 seconds. A rate of 60 seconds reduces the incidence of adverse events such as laryngospasm. A top up dose of 0.5mg/kg can be used if necessary. Onset is within 1 minute and will elicit a horizontal nystagmus and a loss of response to verbal stimuli. The HR, BP and RR may increase slightly. Sedation will wear off after 20 minutes and full recovery should occur by 60-120 minutes. RCEM no longer advise the use of IM ketamine as they suggest it is safer to have IV access available from the start of the procedure should an adverse event occur.
Midazolam: a 2018 BestBets review looking at 6 studies including 2 RCTs has shown that prophylactic benzodiazepines do not significantly decrease the incidence of emergence delirium and they in fact can increase the risk of adverse events, so they should not routinely be given prophylactically. However, midazolam can be used to treat severe emergence, especially in older children. (Aliquots of IV 0.05-0.1mg/kg can be given)
Atropine: atropine was previously used prophylactically to reduce secretions however there is no evidence to support its routine use to prevent laryngospasm or other adverse airway events and again it may increase the rate or adverse events. (Green et al)
Ondansetron: may be appropriate for patients at high risk of vomiting due to ketamine’s emetogenic properties. High-risk groups include those with previous nausea/vomiting during sedation/anaesthesia, older children, those who have received opioids or where ketamine is given intramuscularly. Caution should be used in those at risk of long QT.
Emergency drugs: RCEM suggests key resuscitation drug dose calculations should be done prior to the procedure and these should be accessible, however, no specific drugs are recommended. We suggest that WETFLAG dosing should be done along with the dose calculated for suxamethonium (1.5mg/kg for RSI).
Complications are rare with ketamine. A recent study by Bhatt et al in 2017 (6,760 patients across 5 sites in Canada) looking at propofol, ketamine, propofol/ketamine and ketamine/fentanyl, ketamine alone recorded the lowest serious adverse events at 0.4%. Green et al (2009) showed a 1% risk of noisy breathing requiring airway repositioning, a 0.3% risk of laryngospasm and 0.02% risk of intubation being required.
The capnography trace is there to provide early warning of potential or impending airway and respiratory adverse events. A loss of capnography trace indicates apnoea or obstruction. First check the equipment and monitoring is still in place then check for chest wall movement. If the chest wall is not moving then there is central apnoea. If there is chest wall movement there is obstruction. Airway manoeuvres will relieve obstructive apnoea but will not relieve laryngospasm.
10-year-old boy fell from the top of the climbing frame, landed awkwardly on his left ankle. Primary survey shows no other injuries except obvious deformity of the left ankle.
Summary: procedure appropriate for sedation – post procedure simple airway issues due to obesity
Faculty required: operator/Voice of patient/Nurse in scenario
WETFLAG calculations plus emergency drug calculations
Choice of appropriate drugs and dosing for sedation
Ensure appropriate staff
Checks patient during procedure
Post procedure end tidal CO2 trace is lost (due to obesity)
Chest wall movement
Simple patient positioning and airway manoeuvre opens the airway and CO2 trace returns
Describes post procedure monitoring
Emphasis on appropriate preparation
Systematic approach to adverse events and when to anticipate them
When should you assess a child’s pain and document a pain score in the emergency department when they present with an injury?
A: Wait until the child is seen by a doctor before assessing pain
B: At triage
C: Immediately after giving oral analgesia
D: Within 60 minutes of receiving analgesia for moderate and severe pain
E: When the child or the child’s parents informs you they are in pain
The correct answer is B + D.
A child’s pain should be assessed on arrival in the emergency department, and should be treated appropriately in a timely manner (within 20 minutes for moderate and severe pain). Pain should also be re-evaluated within 60 minutes of receiving analgesia for moderate and severe pain. This process should be repeated for all subsequent doses of analgesia. Reviewing pain should take into account peak of onset for the analgesia given; as such oral analgesics will not work immediately.
Which of the following predict possible airway difficulties in children?
A: C-spine immobilisation
B: Premature birth requiring NICU
C: Trisomy 21
D: Mouth breathing or frequent drooling
E: Reduced mouth opening
All are true.
A through pre assessment prior to sedation should be done to elicit any potential complications and also decide on appropriateness of sedation in the emergency department.
A formal airway assessment should include:
Assessment of dentition for loose and protruding teeth
Presence of soft tissue masses in the mouth
Tempero-mandibular joint mobility
A review of the child’s medical history should also include, congenital abnormalities, birth complications, previous complications during anaesthetics or sedation, noisy breathing, sleep issues and concurrent upper respiratory tract infections.
With millions upon millions of journal articles being published every year, it is impossible to keep up. Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in the UK and Ireland) to point out something that has caught their eye.
As the smallest member of the clan grows older it’s time for my reality based revision to move on from normal neonates to something else. We’ve made it through neonatal nasties and tourniquets on toes. It’s something more commonplace that keeps us up at night – something we’ve all been through – teething.
Cite this article as:
Andrew Tagg. DFTB in EMA #5 – Sticks and stones may break some bones, Don't Forget the Bubbles, 2016. Available at: https://doi.org/10.31440/DFTB.8055
This month in the EMA the DFTB team look at how we might treat a simple forearm fracture.
“Up to a quarter of the paediatric population of the UK present to an ED annually with a large number being due to falls. High-risk activities such as scooter riding, climbing on monkey bars and backyard trampolines are partially to blame although the implementation of safety netting for trampolines has led to a reduction in injuries.”