Make it better: analgesia in the ED


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Author: Nikki Abela / Codes: / Published: 25/02/2020

There is nothing that defines medicine more than the need to “make it better”, and so, nailing analgesia is such a fundamental part of being a practitioner, especially in children.

But the experience of pain is different for different patients, with the exact same situation, and changes depending on what they have presented with.

To properly look after them, we need to tailor our technique to:

  1. The patient
  2. The pain stimulus and the patient surroundings
  3. The procedure they may need

The Patient

Consider for a second the child in front of you. The younger they are, the more likely they are to be pain naive, and have less advanced coping techniques to deal with pain. Their skin, for example, may be more sensitive if they have presented with a burn, and your strategies need to be tailored to that.

As Liz Herrieven taught us her excellent blog, children with Learning Disabilities (LD) may have a higher pain threshold, and those with sensory dysregulation may have difficulty coping with this new stimulus, or may even be unable to articulate how they are feeling. So if you are seeing a child with a LD, consider that there may be more to the problem than what is immediately apparent. For example, if they present with a fractured femur, but seem to be well, that is not to say they are not in pain, so please (please) treat them appropriately and rope in their carers to be able to tailor it to what they are most likely to respond to.

The Pain Stimulus

As emergency medics, we have extensive experience on what to expect with specific injuries. For example, we are frequently (rightly) asked to prioritise patients with burns because we know how painful these are.

This library of knowledge is important to consider what your first management step for a patient should be. You would never, for example, give oral paracetamol as an initial analgesic for a finger amputation, and the same should be said for other forms of pain stimulus.

In children especially, the experience of pain is largely regulated by their emotions and surroundings. Going into hospital is extremely scary, they may have past negative experiences, and even if they dont, its unlikely that they associate hospital with anything good. Add that fear with the new pain stimulus and you have yourself a heightened mix of negative emotions.

This is where play therapists come in. They are worth their weight in gold, and if they dont exist where you work, it is worth learning a few techniques to take on that big emotion and regulate it with distraction, not to get the child to “look at this while I do that”, as that will make them more suspicious, but rather to change that fear and negative experience into something more positive.

If you are looking on reading more on distraction techniques, I asked the Twitter world for their favourite resources – you can have a leaf through the thread there.

The Procedure

Although the child may present in pain, the management of their injury or illness may require temporarily inflicting more pain to make it better, so it is important to consider their pathway of care when deciding what analgesia to give.

For example, femoral shaft fractures are painful in themselves, and splinting will improve that, but putting the splint on will make the pain acutely worse, so take a moment to consider your options (for example a nerve block) to manage that, and prepare early to shorten the painful period as much as you possibly can.

As emergency physicians we have a number of things in our arsenal to address pain in paediatric patients and doing this effectively reduces the need for stronger stuff further down the line. We should aim to get this right for every patient, their pain stimulus and any procedure they need, which could reduce associated morbidity and negative experiences further down the line.

Further Reading:

Pain Management in Adults

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