Analgesics and sedatives (peds)

Introduction

Analgesia and sedation considerations, particularly in the nonverbal population, 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. This page contains considerations for evaluation, options for anesthesia and sedation, and dosages for common analgesics and sedatives.

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.

Neonates

CRIES Scale (used to establish baseline and assess discomfort over time):

CRIES

	0	1	2
Crying	None	High-pitched	Inconsolable
Requires O2	None	<30% FiO2 needed	>30% FiO2 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)

NIPS

	0	1	2
Facial Expression	Relaxed	Grimace
Cry O2	None	Whimper	Vigorous Cry
Breathing Pattern	Relaxed	Variable Breathing
Arms	Relaxed	Restrained
Legs	Relaxed	Restrained
State of Arousal	Not fussy	Fussy

• >1yo: FLACC Scale

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Face	No expression or smile	Grimace, frown, or withdrawn	Quivering chin, clenched jaw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 >3

Wong-Baker

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:

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
• Pain Management in Infants & Children