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.

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Face	No expression or smile	Grimace, frown, or withdrawn	Quivering chin, clenched jaw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

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:

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.

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

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

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

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

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

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
• Pain Management in Infants & Children
• Procedural sedation (peds)