Successful Pediatric Pain Management

1. Matt Ozanich, MHHS, NRP Director of Pre-Hospital Care Trumbull Memorial Hospital Successful Pediatric Pain Management

2. Disclaimer • Always follow local protocols • Always follow administrative policy • Always do what is in the best interest of the patient

3. Objectives • Review the science/theory of pain • Review pediatric pain vs adult pain • Discuss how to set pain mgt goals • Discuss real-world examples of good/bad management of ped pain • Discuss evidence-based suggestions for 2016 on ped pain mgt

4. About Us • Trumbull Memorial Hospital • Medical Command • January 14, 2015 new EMS protocol • Written primarily by EMS providers • Emphasis on pre-hospital studies, not in-hospital studies

5. Dr. Tim Noonan, MD PHTLS 8th ed. panel discussion “Someone else routinely using medical treatments without evidence is not a good reason to do the same.”

6. Charles Kettering American Engineer, General Motors “If you’ve always done it that way, it’s probably wrong.” “High achievement always takes place in the framework of high expectation.”

7. Paramedic Care, 4th Ed. “EMS has, historically, done a poor job of treating pain in the prehospital setting.”

8. What is Pain? • Physical discomfort caused by tissue abnormalities

9. What is Pain? • How do we control this?

10. Awww not this again…

11. Here’s what we know for sure [Blank Page]

12. Pain Theory Physical Abnormalities (Extrinsic) Psychological Duress (Intrinsic) Systemic Changes (Intrinsic)

13. Pain Theory Acute Pain Chronic Pain Extrinsic Intrinsic Extrinsic Intrinsic

14. Specificity Theory Receptor (brain) Pathway (spinal tract) Origin (nociceptor) Moayedi & Davis 2013

15. Pain Theory Gate Control Theory Nociceptor (pain receptor) Pathway Moayedi & Davis 2013

16. Pain Theory Gate Control Theory Somatosensory Pathway (normal sensation) inhibits Nociceptor

17. Pain Theory Central Sensitization Theory Latremoliere & Woolf 2009

18. Pain Theory Adrenergic sensitivity theory Injury Nociceptor stimulated Pain Catecholamines release Vasoconstriction Reduced pain Catecholamines again… By unknown mechanisms… Pain sensitization Tissue ischemia Inflammation Increased pain Alpha 2 + Inflammation = Reperfusion Reperfusion = Increased pain Hey man, this hurts! Carroll, Mackey, Gaeta 2007

19. Pain mgt perceptions

23. In hospital The patient vs The treatment

24. Prehospital The patient vs The treatment

25. Pedsvs Adults in Pain Pediatrics Adults Complex concerns Understands injury Response is more internally mediated • Simpler concerns • Injury misconceptions • Response mediated by environment

26. Eric Fleegler, MD 2016

27. Assessment and decision making

28. The Wong-Baker Scale

29. Pain Scales Pain scales look great in the chart Use the “my child” rule… Use the Golden Rule Use your Humanity…

30. Okay, I think I understand pain… What can I do to make a difference?

31. Why most prehospital pain algorithms fail • No established goals • We fail to educate or encourage • We fail to adapt • We use in-hospital algorithms • We don’t consider pain mgt alternatives

32. How NOT to fail! • Establish goals • Educate on pain, encourage mgt • Adapt (CQI based on goals) • Focus on what works in the prehospital setting

33. Establish Goals Fix pain • How often can it be managed with more basic maneuvers? • How often should complaint of “pain” receive medication? • What is your measure of success?

34. Establish Goals Document that we fixed pain • Pain score matters in documentation, not practice • Encourage providers to document comfort response • Higher comfort > lower pain score

35. Educate on Pain Let everyone know how pain works • Explain pain • Explain the role of stress & sympathetic tone • Explain the role of psychological and distraction options • Explain the pharmacology

36. Educate on Pain Educate the differences between ped pain and adult pain • Peds respond to environment • Peds respond to stressors • Peds have misconceptions with injury

37. Educate on Pain Pain management is safe, effective, and expected!

38. Adapt CQI based on goals • Are we meeting goals? • If not, how do we improve this? • If so, and the goals are insufficient, how do we make them better?

39. Our System – CQI and Goals 2010-2014 • Primarily IV morphine based • Minimal education on meds • Not encouraged to use them • Afraid of meds • No CQI performed on effectiveness

40. Our System – CQI and Goals 2015 • LOTS of route options • LOTS of education • EXPECTED to MEDICATE!!!!! • Alleviated fears • Massive new CQI system • EMS providers give input monthly

44. Our Goals • Legitimate pain reported gets mgt • Good documentation • Proper dose administered • Identified response from dose • Relaxation, restfulness

45. Those aren’t normal hospital goals… “Matt, your goals are nonspecific” • I am a transformational leader • Most hospital goals are transactional, which is less effective at obtaining results

47. Pediatric interventions

48. Non-Pharmacological

49. Psychological Support Peds respond to environment • Make the environment suitable • Parents • Comfortable distance • Eye level • Noise / lights Peds respond to stressors • Calm and reassure • Distraction • Laughter

50. BLS Maneuvers • Splinting • Covering • Resting • Position of comfort • Keep the wound clean • Ice, where acceptable