We searched the Cochrane Library, Medline, PubMed, and relevant specialty journals (all from 1980 to January, 2014). We used the search terms “pediatric pain”, “pain assessment”, “pain management”, “chronic pain”, “pain scores”, “pain protocols”, and “emergency department”. We selected publications from the past 15 years with an emphasis on the past 3 years, but we did not exclude commonly referenced and influential older publications. We also searched references of articles identified by our
ReviewCurrent concepts in management of pain in children in the emergency department
Introduction
Pain is a common symptom in children presenting to emergency departments. Under-treatment of pain (commonly labelled oligoanalgesia) has been frequently reported particularly in younger children, those with cognitive impairment, and children in developing countries. Organisations such as the Joint Commission International have made pain assessment and management a priority issue.1 Initiatives include recording of pain scores, staff education, and quality improvement processes.2, 3, 4, 5 Such efforts have fostered advances in the pharmacological and non-pharmacological treatment of pain in children. We review the state of emergency-department pain management in children, including recognition, assessment, and non-pharmacological and pharmacological treatment.
Section snippets
Recognition and assessment of pain
Pain as a presenting complaint for episodic illnesses, acute injuries, or exacerbation of chronic conditions, accounts for up to 78% of emergency department visits.6 Musculoskeletal injuries are common;7, 8, 9 27–42% of children sustain a fracture before the age of 16 years.10, 11 Other common causes include headache, otalgia, sore throat, and abdominal distress.7, 12, 13, 14 About half of patients report their pain as moderate to severe.7, 15, 16 A visit to a noisy, crowded emergency
Pain in children with chronic illness
Acute pain is common in children with chronic illnesses such as sickle cell disease, haemophilia, juvenile idiopathic arthritis, inflammatory bowel disease, hereditary angioedema, cancer, Mediterranean fever, Fabry disease, and Gaucher disease. Some typical features of acute pain (eg, tachycardia, diaphoresis, facial expression) might not manifest in these children, as they attenuate with time in chronic pain.29 These children and their families often have heightened fear and anxiety related to
Physical comfort measures and distracting activities
Psychological, behavioural, and physical interventions, stratified by age and development, can be used as adjuncts to pharmacological management.59, 60, 61, 62, 63, 64 In children, disorders causing acute pain are often accompanied by anxiety and distress. A stepwise approach to managing acute pain and anxiety combines pharmacological and non-pharmacological interventions as integrated treatment (figure 1).
Non-pharmacological approaches can be divided into two general categories: physical
Analgesic therapy
Analgesic therapy is warranted whenever non-pharmacological approaches are insufficient, or when they are unlikely to achieve the needed pain relief when given alone. We present various recommended options in Table 1, Table 2. Inhaled nitrous oxide and parenteral ketamine are often administered for sedation and analgesia during procedures; however, we do not discuss these drugs further here given the limited published experience for non-procedural analgesia in children.
Routes of administration
The oral and intranasal
Future directions
Future initiatives in emergency-department paediatric pain management will focus on developing condition-specific protocols to optimise pain recognition, assessment, and management, especially for children with cognitive impairment, recurrent pain syndromes, and chronic illness. How can we know when we have successfully provided sufficient analgesia, and when our efforts remain inadequate? When does anxiety predominate over pain such that anxiolytic agents might be more effective than
Search strategy and selection criteria
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