Authors: Liz Herrieven, Charlotte Davies / Editor: Liz Herrieven / Codes: / Published: 21/02/2023
Pain is probably the most common reason for people to attend the Emergency Department (ED). It should be our bread and butter, as Emergency Physicians. Getting it right isnt easy though. Not only are there the physical causes to unpick, but also the impact of psychological, cultural and contextual influences to trip us up. Time and again, the RCEM national audits, and more recently quality improvement projects, have shown that, when managing children in pain, emergency departments are consistently poor at assessing and treating pain, reassessing and responding to that reassessment1.
With regards to children, some of this will be to do with our lack of confidence when assessing pain in pre-verbal or non-verbal children. Its much easier to recognise someone is in pain when they say, Oh doctor, this is rather painful, you know. Some of our poor performance will also be to do with reluctance to use strong analgesics in children, for fear of causing side effects. It is true that, for those more used to managing adults, many medications are less predictable in children, who may, depending on their age and weight, have different liver or renal metabolism, have smaller fat stores or a larger body weight percentage of water, for example. But we still have a duty to manage pain appropriately, whatever the age of our patients.
Assessment of Pain
Assessing pain is more than just asking How bad is it, on a scale of 0 to 10?. If were going to do that, we need to give some examples and make it relatable for the patient. What does their pain stop them doing? Can they cope with daily activities whilst theyre in pain? Have they had to alter what they do or how they move? If their pain allows them to carry on with their daily life, but with some niggles, then its probably a 2 or a 3. If its too painful to do anything except think about the pain, its probably a 9 or a 10. Give them context and youll get a more reliable answer.
Visual scales can be really useful. Wong-Baker faces for children are commonly used, but again need to be used appropriately. The child has to understand what you want from them. They have to be able to show you which face represents how they feel when in pain. Otherwise, who wouldnt just point at the smiley face because it looks more friendly than the crying face?
For those who cannot verbalise their pain, whether adults or children, we rely on non-verbal cues such as facial expression, activity, posture or noises. The FLACC scale is a more formal way of assessing pain using these things, particularly designed for pre-verbal children.
For some people, particularly those who are autistic or who have sensory processing challenges, pain may be expressed in different ways, specific to the individual. DisDAT (the Distress and Discomfort Assessment Tool)2 is a way of trying to record this. Its not something wed complete in ED, but is designed to be filled in by someone who knows the person well, perhaps over time, noting behaviours or characteristics that are present when the person is in discomfort. The completed tool can then be used as a reference when the person is being assessed by someone who doesnt know them well (such as an Emergency Physician).
The Paediatric Pain Profile3 is used in a similar way for children with severe physical impairments or learning disability. Hospital passports can also be a really useful way of finding out more about how a person might present if they are in pain4 and dont forget you can always ask parents or carers. Admit they are the expert in their loved one and ask them how their child, brother, cousin, resident would usually show them they are in pain.
The Pain Pathway
Once weve decided someone is in pain, we then need to manage it. Pain follows a well-defined pathway, which gives us plenty of opportunity to intervene. First off, trauma, inflammation or infection triggers the local release of chemical mediators such as prostaglandins, which trigger an action potential. This is transduction. Next, the action potential travels along the nerves to the spinal cord and up to the brain. This is transmission. Signals are received by the brain perception and the brain attempts to start to tackle the pain by releasing endorphins and serotonin modulation.
Management of Pain
We can start to manage pain right at the beginning of the pain pathway. Chemical mediator release, and so transduction, can be reduced by the use of splints, ice packs and elevation.
Analgesic medication and local anaesthetics work on the transmission and perception stages. Paracetamol and ibuprofen are great simple analgesics. Codeine isnt used in children its not great in adults either. It is pretty unpredictable in its metabolism (to morphine) with some getting a huge morphine hit and others nothing at all. Children with airway issues and sleep apnoea are particularly at risk. NSAIDs like diclofenac are a great middle ground though. Weve all heard of the pain ladder and know how to work our way up it, prescribing stronger analgesia as we go, but dont be afraid to start at the top of the ladder for someone in significant pain. That may mean morphine, diamorphine, fentanyl or ketamine, for example.
| Cardiac Sounding Pain | GTN Spray or Infusion | Works in seconds but dont use it to make a diagnosis. |
| Urinary retention | Catheterisation | Works immediately |
| Constipation | Consider enemas but rule out other causes of discomfort first. | Absorption variable |
| Spasmodic pain | Buscopan | Poor oral absorption, but very useful in IBS of bowel and chest. |
| Gynae pain | NSAIDs and warmth | Consider a hot water bottle if any available. |
| Sickle pain | Warmth, fluids Analgesia as per plan | |
| Heartburn | Gaviscon | Works immediately. PPIs can take a few weeks to work, and pink ladies arent recommended any more. |
| Migraines | Aspirin + anti-emetic as per local migraine policy | |
| Burns | Cooling for 20min in tepid water | |
| Broken bones | Comfortable support /splints Nerve blocks | |
| Gout | Prednisolone | On specialist advice? |
| Ophthalmology r/v | For glaucoma | |
| Procedural | Entonox, Penthrox (not licenced for use in children), conscious sedation | |
| Rib Fractures | Topical lidocaine patches SAP blocks | |
| Dental Pain | Abscess drainage + dental blocks (if trained) | |
| Back Pain | Consider diazepam Trigger point injections if trained. |
Directed Analgesia
Think about the route youre going to use, too. Oral medications are acceptable to most patients, although if they are vomiting then it might be best avoided. Some children (and some adults) might find swallowing medication more challenging, and dont forget that delayed gastric emptying in trauma may make the speed of onset of medications such as oral morphine solution unpredictable or delayed.
Intranasal is great. Diamorphine, fentanyl and ketamine can all be given this way, with pretty quick onset of action. Its acceptable to most patients, too.
Dont forget rectal. Diclofenac PR, in particular, is an excellent analgesic for renal colic, for example.
Inhalational analgesia (Entonox 50:50 nitrous oxide and oxygen, or Penthrox methoxyflurane) can be a great way to get someone comfortable in a hurry, and gives them some control over their treatment. Dont forget that nitrous oxide expands and will cause problems if given to patients with bowel obstruction, pneumothorax or pneumocephalus, for example, and Penthrox isnt licensed for use in children. Volatile analgesics and anaesthetics arent a great option for the environment, either.
We often shy away from cannulating children to give pain relief after all, cannulating children is difficult and distressing for us as well as for the children. Dont write off intravenous analgesia completely though. The intravenous route allows for great titration and the opportunity to actually get our patient comfortable. Its a trade-off yes, theres an uncomfortable procedure to get through, but then we can get rid of your pain. If you make this promise, though, dont break it.
Remember how useful nerve blocks, local anaesthetics and topical treatments such as LAT gel5 can be, and use these alongside your traditional analgesia.
| Step Zero | Directed Analgesia | See table above |
| Step One | Paracetamol | There is no evidence IV works any more effectively or quicker than PO. IV is more expensive. Dont forget PR as an option. |
| Step Two | NSAIDs Ibuprofen, Diclofenac | See BNF. Always start with ibuprofen as least cardio-toxic. Evidence around bigger doses being more effective is conflicting – but anecdotally bigger doses are probably better. PR diclofenac useful in renal colic. |
| Step Three | Weak Opiates | Codeine should never be used for headaches, should be carefully considered in the elderly and never used in children. It should never be given as a sole agent – give with paracetamol. 60mg is not significantly more effective than 30mg but has considerable side effects. Tramadol should only be given if the patient is on it already- its a horrible drug. Codeine and tramadol should never be given in combination. |
| Step Four | Nefopam | Consider it carefully – it shouldnt be used lightly, especially in the elderly. But works well. Not used for children. |
| Step Five | Strong Opiates Morphine – PO, SC, IM or IV Oxycodone Fentanyl, diamorphine | Oral is often preferable and works in about 30min. IV peaks in 20min. Oxycodone is better for adults with renal impairment. Intranasal fentanyl or diamorphine are fast-acting and can help avoid needles in children. |
| Step Six | Neuropathic Agents Gabapentin, amitriptyline | These take a while to work and should not be initiated in the emergency department. |
Analgesic Ladder
When it comes to perception and modulation of pain, then keeping calm, being reassuring and giving clear explanations are all key. For children, distraction can be great. For adults, distraction can also be great, but might be more along the lines of chatting and putting them at ease, rather than blowing bubbles. For adolescents, let them have their social media fix. Dont forget to also keep parents and carers calm as anxiety is truly infectious.
| Analgesia | Provide analgesia or pain relief rather than pain killers (theyre a nocebo). Be positive in your belief of their effectiveness. Consider directed or general analgesics and dont forget adjuncts such as LAT gel or nerve blocks. |
| Breathing |
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| Comfort |
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| Distract | Change the focus from the discomfort. Provide a task. As you lie comfortably here, plan what youre going to do in the future when youre comfortable. |
| For more details and resources on these techniques, take a look at the Handbook of Communication in Anaesthesia & Critical Care: A Practical Guide to Exploring the Art by Allan Cyna et al. and consider the RCoA toolkit on preparing your mind – many transferrable skills. | |
The ABCD of Pain Management
Once youve done your best to manage your patients pain, dont stop there. Reassess and respond to that reassessment. If they are still in pain, or the pain returns, you still have work to do.
Managing pain not only helps our patients thats probably why theyre in the ED, after all but it can give us great job satisfaction, and thats always worth having.
References
- Royal College of Emergency Medicine. Pain in Children. National Quality Improvement Project. National Interim Report 2020/21. Jan 2022.
- Distress and Discomfort Assessment Tool (DisDAT). St Oswald’s Hospice.
- Paediatric Pain Profile (PPP).
- Liz Herrieven, Erica Donovan and Tara McCormack . Hospital Passports, Don’t Forget the Bubbles, 2021.
- Carley S. Please Use Less Ketamine LAT Gel At St.Emlyns, 2012.