Post on 27-Dec-2015
Pain evaluation
Each child coming in A&E with pain,
needs to have an evaluation of his pain.
This evaluation is necessary to chose the
adapted painkiller and to follow the
efficiency of the treatment.
Auto-evaluation is the best if possible
Different tools help evaluation (pain scale)
Pain assessment / age
Less than 4 years > Behavioral scaleBetween 4-6 years > Face scaleMore than 6 years > VAS or numeric scale
Scale type VAS Face Behavior
Mild pain 1 - 3 2 1 - 2
Moderate pain 3 - 5 4 3 - 4
Severe pain 5 - 7 6 5 - 6
Very severe > 7 8 - 10 7 - 10
Painkiller 3/10 4/10 3/10
Different types of painkillers
Level Painkiller
1 Paracetamol
2Codeine
Non Steroid Anti-inflammatory
Tramadol
3 Morphine
How to chose painkillerLevel 1 & 2: can be administrated by the nurse
(triage nurse)Level 3: medical prescription onlyAssociation between different levels is possible
(ex: 1 + 2 or 1 + 3)
No pain Mild painModerate
painSevere pain
Very severe pain
No use Level 1 Level 1 or 2 Level 2 or 3 Level 3
Level 1 = ParacetamolDOLIPRANE / EFFERALGANDose 15mg/Kg by mouth (better than intra-rectal)
< 5 KgDoliprane 100mg
½ sachet
5 – 8 KgDoliprane 100mg
1 sachet
8 – 12 KgDoliprane 150mg
1 sachet
12 – 16 KgDoliprane 200mg
1 sachet
16 – 27 KgDoliprane 300mg
1 sachet
> 27 Kg Dopirane 500mg
Level 2 : CodeineCODENFAN 0.5ml/Kg/6h (soon available in FVH)EFFERALGAN Codeine (only if > 15Kg)
Weight Posologie
15-22 Kg ½ tablet / 6h
23 – 30 Kg ½ tablet / 4h
31 – 50 Kg 1cp / 4 to 6h
> 50 Kg 1 to 2 tablets/ 4h
Level 2 : Tramadol
Authorized for children of 15 years old or more
1 tablet /every 6 hoursAssociation with paracetamol possibleThere is a sirup of tramadol (Topalgic
100mg/ml for children > or = 3 years) but not available in FVH…
Level 2 : Non Steroid Anti-inflammatory = Children’s Ibrafen® sirup
If needed, repeat dose every 6 hours
Age Weight (Kg) Dose(teaspoon)
Under 2 <11 Kg 1/2
2 - 3 11 - 16 1
4 – 5 16 - 21 1.5
6 – 8 21 - 27 2
9 – 10 27 - 32 2.5
11 32 - 43 3
Level 3 : Morphine IV
Indicated if severe or very severe painUse only if medical supervision (Pain,
consciousness, respiratory rate)
Ventilation device available (balloon, high
concentration mask, Oxygen) and Naloxone available.
Contre-indication: hepatic failure, asthma in crisis, cranial trauma, hypersensitivity to morphine
Management of morphine
Use bolus of morphine (titration)
First dose : 0.1mg/Kg IVD (always < 5mg)
Reevaluation every 5 minutes (use the same scale)
Reinjection of 0.025mg/Kg every 5 to 7 minutes if EVA > 4 (objective = EVA < 4)
There is no maximum dose but medical assessment is necessary after 5 injections
Preparation of morphine
1 ampoule of morphine = 10mg
Dilute the ampoule in 9ml of serum You get 10mg / 10ml (1mg/1ml)
First dose 0.1mg/Kg
Example: child 20Kg > needs 2mg = 2ml
of the diluted preparation.
Next bolus 0.025mg/Kg > 0.5mg = 0.5ml
Safe control during morphine treatment : 3 criteria
1. Re-assessment of the pain
2. Conscious evaluation (sedation score)
3. Respiratory Rate
Score Sedation Clinical signs
0 No sedation Alert, eyes opened
1 Mild sedation Eyes open on demand
2 Important sedation Eyes open on stimulation
3 Very severe Impossible to wake up
Respiratory depression
Respiratory rate is the best criteria with consciousness
Age Respiratory Rate
< 1 year > 20/min.
1 to 5 years > 15/min.
> 5 years > 10/min.
In case of overdose signs
Sedation score < 2 and RR to law (depend of age)
Stimulate the child and ask him to breath
Oxygenation with high concentrated mask if SaO2 < 94% 6 to 8l/min
If no improvement after stimulation, use Naloxone (NARCAN®)
Use of Naloxone = NARCAN®
1 ampoule = 0.4mg = 400g = 1ml
Posologie: 1 to 2 g / Kg IVD
Dilute 1 ampoule of 1ml in 9 ml of serum
Inject 1ml by 1ml until the child recover
normal conscious & respiratory rate
Problem: the antalgic effect of morphine is
removed
Criteria of discharged after use of morphine in children
Only after 2 hours of surveillance in A&E (after the last bolus of morphine)
Child awake (sedation score = 0)
Respiratory rate normal for the age
Parents agree for assessment at home (give and explain special form for assessment after use of morphine)