View source for Analgesics and sedatives (peds)

==Background==
*Requires a more careful approach than typically needed in the adult population. 
*Children may require sedation for procedures that are done with topical anesthetic in the adult population and evaluation of pain in infants and young children can be challenging.

==Evaluation==
*There are a number of well established frameworks for evaluating pain that are helpful in the pediatric ED; which framework works best is dependent on the age of the patient and provider preference<ref>“Pediatric Pain.” n.d. Accessed October 14, 2022. http://www.emra.org/books/pain-management/pediatric-pain/.</ref>.

===Neonates===
CRIES Scale (used to establish baseline and assess discomfort over time):
{| class="wikitable"
|+ CRIES
|-
!  !! 0 !! 1!! 2
|-
| '''Crying''' || None || High-pitched || Inconsolable
|-
| '''Requires O<sub>2</sub>''' || None || <30% FiO<sub>2</sub> needed || >30% FiO<sub>2</sub> needed
|-
| '''Increased Vital Signs''' || Normal HR and BP || Increased HR and BP <20% || Increased HR and BP >20%
|-
| '''Expression''' || Normal || Grimace || Grimace and Grunt
|-
| '''Sleeplessness''' || None || Wakes frequently || Awake constantly
|}

===Infants===
* <1yo: Neonatal Infant Pain (NIPS) Scale (score of >5 generally should be treated pharmacologically)
{| class="wikitable"
|+ NIPS
|-
!  !! 0 !! 1!! 2
|-
| '''Facial Expression''' || Relaxed || Grimace ||
|-
| '''Cry''' || None || Whimper || Vigorous Cry
|-
| '''Breathing Pattern''' || Relaxed || Variable Breathing ||
|-
| '''Arms''' || Relaxed || Restrained || 
|-
| '''Legs''' || Relaxed || Restrained || 
|-
| '''State of Arousal''' || Not fussy || Fussy ||
|}
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* >1yo: FLACC Scale
{| class="wikitable"
|+ FLACC
|-
!  !! 0 !! 1!! 2
|-
| '''Face''' || No expression or smile || Grimace, frown, or withdrawn || Quivering chin, clenched jaw
|-
| '''Legs''' || Relaxed || Restless, tense || Kicking, drawn up
|-
| '''Activity''' || Lying quietly or easy movement || Squirming, tense || Arched, rigid, or jerking
|-
| '''Cry''' || None || Moaning, whimpering, complaining || Steady crying or screaming
|-
| '''Consolability''' || Relaxed || Distractable || Difficult to console or comfort
|}

===Verbal Children >3yo===
For pain assessment in the verbal child who is >3yo, consider using a visual pain scale such as the Wong-Baker scale (shown below).
[[File:Wong-Baker.jpg|thumb|left]]
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==Escalation of Care==
Escalation of care generally depends on the source and severity of pain that the patient is experiencing. Consider starting with non-pharmacologic interventions and escalating to topical, oral, or IV as appropriate.
===Non-pharmacologic methods===
First line of care for an uncomfortable infant or child in the ED should include non-pharmacologic methods such as heat or icing. Distraction can also be a useful technique for consolation, including:
* Pacifiers
* Multimedia displays/videos
* Engagement with Child Life Specialist


===Topical Anesthetics===
While not as frequently used in the adult context, topical anesthetics play a major role in pain management in pediatrics. The most frequent uses for topical anesthetics are enable PIV placement and to "pre-treat" open wounds prior to bedside evaluation and repair. Common options include:
{| class="wikitable"
|+ Topical Anesthetics
|-
! Name !! Principal Indication !! Onset/Duration
|-
| LET || Use on open wound for laceration repair || 30-45 minutes/variable
|-
| EMLA || Use on intact skin. Can assist with PIV placement, LP, or abscesses || 45-60 minutes/~120 minutes
|-
| LMX || Use on intact skin. Can assist with PIV placement, LP, or abscesses || 20-30 minutes/~60 minutes
|}

===Intranasal and IV analgesia===
If the above are not adequate or appropriate for the patient at hand, providers can consider inhaled analgesics or, if IV access is available, IV analgesia. As with adult patients, it is recommended to avoid opioids when possible. See below for common dose ranges for analgesics in the pediatric population.

==Considerations for Sedation==
In general, the indications for pediatric sedation are to relieve pain, reduce anxiety, and ensure cooperation/patient safety during a procedure. Once it is determined that a pediatric patient will need sedation, the evaluation of said patient is essentially the same as for adults. Collect a medication list and determine allergies before conducting an airway evaluation. Consent the parent(s) prior to sedation. The following are a set of commonly used sedatives along with their indications, courtesy of Dr. Michael Mojica's PEM Guides.

{| class="wikitable"
|+ Etomidate
|-
| Class || Imidazole sedative hypnotic
|-
| Pharmacology || Onset: 1 minute, Duration: 3-12 minutes
|-
| Benefits || Cardiovascular stability, decreases intracranial pressure
|-
| Adverse Effects || Transient cortisol depression, myoclonic activity
|-
| Indications || Non-painful radiologic procedures (e.g. head CT)
|-
| Contraindications || Adrenal insufficiency, chronic steroid use
|-
| Dose || 0.2-0.4 mg/kg
|-
| Comments || Notify parents and CT technicians before administration that myoclonic jerks may occur, that they do not represent seizure activity and that they are typically is very brief in duration
|}

{| class="wikitable"
|+ Propofol
|-
| Class || Sedative-hypnotic
|-
| Pharmacology || Onset 1-2 minutes, Duration 3-5 minutes
|-
| Benefits || Titratable, decreases ICP, Antiemetic, Anticonvulsant
|-
| Adverse Effects || Respiratory depression
Apnea (usually resolves with jaw thrust)
Cardiovascular depression: Hypotension
No analgesic properties, painful administration
|-
| Indications || Long duration nonpainful, radiologic procedures (e.g. MRI), post rapid sequence intubation for head trauma
|-
| Contraindications || Hypotension: Maximize volume status prior to use. < 6 months associated with high rate of complications, Egg/Soy allergies are no longer considered a contraindication
|-
| Dose || Initial dose: 1.5–2.0 mg/kg
Subsequent dose: 0.5-1.0 mg/kg Q1-3 minutes to effect
Infusion: 250 µg/kg/minute (0.25 mg/kg/min)
|-
| Comments || An IV fluid bolus should be readily available for hypotension
|}

{| class="wikitable"
|+ Fentanyl
|-
| Class || Opioid
|-
| Pharmacology || Onset 2-3 minutes, Duration 20-60 minutes
|-
| Benefits || Analgesic, Hemodynamic stability (Less histamine release), Reversible with Naloxone
|-
| Adverse Effects || Respiratory depression
Chest wall rigidity with high doses or rapid administration
|-
| Indications || Painful conditions and procedures
|-
| Contraindications || Pt with poor respiratory drive
|-
| Dose || IV: 1 mcg/kg, maximum dose 100 mcg
IN: 1-2 mcg/kg, maximum dose 100 mcg
|-
| Comments || Chest wall rigidity may require Naloxone or a paralytic
|}

{| class="wikitable"
|+ Morphine
|-
| Class || Opiate
|-
| Pharmacology || Onset 5-10 minutes, Duration 2-4 hours
|-
| Benefits || Analgesic, Reversible with Naloxone
|-
| Adverse Effects || Respiratory depression, Hypotension (histamine release)
|-
| Indications || Painful conditions and procedures
|-
| Contraindications || Pt with poor respiratory drive
|-
| Dose || 0.1 mg/kg
|}

{| class="wikitable"
|+ Midazolam
|-
| Class || Benzodiazapine
|-
| Pharmacology || IV: Onset 1-2 min, Duration 30-60 min 
|-
| Benefits || Amnestic, anxiolysis, anticonvulsant, Reversible with Flumazenil
|-
| Adverse Effects || Respiratory depression
Paradoxical agitation in children
|-
| Indications || Anxiolysis
Use in conjunction with an opioid for painful procedures
|-
| Contraindications || Pt with poor respiratory drive
|-
| Dose || IV: 0.1 mg/kg
IN: 0.3-0.5 mg/kg, maximum dose 10 mg
|}

{| class="wikitable"
|+ Dexmedetomidine
|-
| Class || Alpha 2 agonist
|-
| Pharmacology || Sedative, anxiolytic and mild analgesic properties
Lipid soluble: Readily cross the blood brain barrier
|-
| Benefits || Minimal effects on respiratory function
|-
| Adverse Effects || Cardiovascular effects: Hypotension, bradycardia
Use with caution in patients with liver and renal disease
|-
| Indications || Non-invasive imaging
|-
| Dose || Loading: 1-3 mcg/kg over 10 minutes, may be repeated
Infusion: 0.5-2 mcg/kg/hour
Can be given orally and intranasally as well
|-
| Comments || Compared to Propofol:  
Similar cardiovascular adverse events without respiratory depression
Analgesic 
Longer induction, recovery and discharge times
An IV fluid bolus should be readily available for hypotension
|}

==Disposition==
Pediatric patients are generally safe to be discharged home if their pain is well-controlled, they can walk unsupported (if appropriate for age), and can tolerate fluids. If pain is uncontrolled after escalation of care in the emergency department (particularly if a clear source of pain has not been identified), consider admission for further workup and management.

==Pediatric doses for Common Analgesics==
===Non-Opioid===
[[Acetaminophen]]
*PO/PR: 10-15mg/kg/dose q4-6hrs
*Children’s Tylenol is 160mg/5ml
*Max: 75mg/kg/day or 4000mg/day
[[Ibuprofen]]
*PO: 4-10mg/kg/dose q6-8hrs
*Children’s Motrin is 100mg/5ml
*Max: 40mg/kg/day
[[Ketorolac]]
*IM/IV: 0.5mg/kg/dose q6hrs
[[Tramadol]]
*PO: 1-2mg/kg/dose q4-6hrs
===Opioid===
[[Naloxone]] ([[opioid overdose]] reversal)
*IV/IM: 0.001-0.02mg/kg/dose
[[Morphine]]
*IM/IV: 0.05-0.2mg/kg/dose q2-4hrs
[[Hydromorphone]]
*IV: 0.015mg/kg/dose q4-6hrs
*PO: 0.03-0.08mg/kg/dose q3-4hrs
[[Fentanyl]]
*IV: 1-2 mcg/kg/dose q1-2hrs
*IN: 1-2 mcg/kg/dose via atomizer
[[Oxycodone]]
*PO: 0.05-0.15mg/kg/dose q4-6hrs
[[Codeine]]
*PO: 0.5=1mg/kg/dose q4-6hrs
[[Methadone]]
*IV/PO: 0.05-0.1mg/kg/dose q6hrs

===Combination Medication===
Acetaminophen with Codeine
*PO: 0.5-1mg/kg/dose of codeine q4-6hrs
Acetaminophen with Hydrocodone
*PO: 0.15mg/kg/dose of hydrocodone q4-6hrs
Acetaminophen with Oxycodone
*PO: 0.05-0.15mg/kg/dose of oxycodone 14-6hrs

==Pediatric doses for Common Sedatives==
[[Midazolam]]
*IM: 0.05-0.15mg/kg; max 10mg
*IV:
**6mo-5yr: 0.05-0.1mg/kg initially with up to 0.6mg/kg needed; max 6mg
**6yr-12yr: 0.025-0.05mg/kg initially with up to 0.4mg/kg needed; max 10mg
**12yr-16yr:1-2mg initially with up to 2.4-5mg needed; max 10mg
*PO: 0.25-0.5mg/kg; max 20mg
[[Lorazepam]]
*IV/PO: 0.05-0.1mg/kg q4-8hrs
[[Ketamine]]
*IV: 0.5-2mg/kg
*IM: 3-7mg/kg
[[Chloral hydrate]]
*PO: 25-50mg/kg
[[Propofol]]
*IV: 1-2mg/kg over 30 seconds
[[Etomidate]]
*IV: 0.3mg/kg

==See Also==
*[[Pediatric Emergency Drug Reference Card]]
*[[Acute pain management|Acute Pain Management]]
*[[Pain_management_in_infants_and_children|Pain Management in Infants & Children]]
*[[Procedural sedation (peds)]]

==References==
<references/>

[[Category:Pediatrics]]
[[Category:Pharmacology]]
[[Category:Palliative Medicine]]