Are you attending the state EMS meetings on July 16-18 or CLINCON on July 17-19 in Orlando? Please join us at the
Florida EMSC Advisory Committee Meeting
on Wednesday, July 17 at 1:00 pm, or come by the
PAMI/PEDReady Booth
at CLINCON’s Welcome Reception on July 17 at 4:30–6:30 pm.
Please help spread the word about the PEDReady PE
2
ARL to your local nursing, paramedic, PA and medical schools! See how
EMS students
can benefit in this week's
PEDReady Champion of the Week
section.
Is there a
champion
(person, school, agency, hospital or organization) in your area doing great things for pediatric emergency care? This includes prevention, EMS, EDs, education or examples of outstanding pediatric care. Email us at
pedready@jax.ufl.edu
.
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Encourage others to sign up for the PEDReady listserve & weekly newsbrief, the PE
2
ARL, by sharing this link:
http://bit.ly/flpearl
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Focus | Pediatric Pain Management Case Scenario
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Pain Management Recipes (Pharmacologic): IV and IN
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EMS SCENARIO:
You arrive at the home of a 2-year-old who pulled hot water and noodles out of the microwave (name your mechanism: coffee, pot of boiling water, etc.). She has significant burns to her chest, abdomen and shoulders. Your rough estimate is 15% partial thickness burns. She is running away from you and screaming in pain. Mother is crying and asking if you will report her to DCF. Child is 1-800-BAD-OUCH. In our last PE
2
ARL, we determined the FLACC scale was appropriate for a child of this age. FLACC=8!
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ED SCENARIO:
EMS arrives with a screaming 2-year-old who pulled hot water and noodles out of the microwave on to her chest, abdomen and legs. She has 15% partial thickness burns. No IV access. 1-800-BAD-OUCH! In our last PE
2
ARL, we determined the FLACC scale was appropriate for this case. FLACC=8!
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What are your options for treating this patient’s pain?
Considerations: IV vs. no IV access, duration of transport
What are your pain management recipes?
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1. How would you initially treat this child’s pain?
A)
Attempt IV and administer Fentanyl 1 mcg/Kg or Morphine 0.1 mg/Kg
B)
Administer Fentanyl intranasally (IN) while calming child and attempting IV
C)
Administer Ketamine IV at dose of 2 mg/Kg or if not IV give IM at 4-5 mg/Kg
D)
Administer midazolam anyway possible to calm the kid down
Answer: A or B, depending on your situation and setting
Why are C and D incorrect?
2. How does burn pain differ from other types of pain such as a fracture?
3. Why is acute pediatric pain management garnering national attention?
Let's find out the answers...
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1. How would you initially treat this child's pain?
This answer depends on your setting, situation, pediatric experience/skill set, type of pain, age and developmental stage, and other factors. There is no simple recipe! Always consider a stepwise approach and add nonpharmacologic approaches to your pharmacologic “recipes.”
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Intranasal (IN) Medications
are a great option in children
. ED and EMS providers often struggle to obtain pediatric IV access, especially when children are crying, thrashing or riding in the back of an ambulance with an anxious parent watching over your shoulder. Or how about that chubby toddler with no veins in sight, or if the skin is burned or dehydrated?
- Fentanyl, midazolam and ketamine can be given IN
- IN medications work rapidly due to the vascular nasal turbinates and proximity to the olfactory nerve
- Fentanyl IN dose = 1.5-2 mcg/kg q 1-2 h or via nebulizer 1.7-3 mcg/kg. Max dose is 3 mcg/kg or 100 mcg
- Always use an atomizer and concentrated solutions
- Midazolam (Versed) provides anxiolysis and sedation but not analgesia (making answer D incorrect)
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Ketamine Indications and Dosing
Ketamine has been used effectively and safely in children for decades; however, now ketamine is used for a variety of indications with varying dosages. The scenario question above used a procedural sedation or dissociative dose of ketamine versus the analgesic sub-dissociative dosage (making answer C incorrect). If using a dosing tape or system, be sure you check the indication and use the correct dosing range. The IN dose for ketamine has a wide range with some studies using ≥ 1.5 mg/kg. See the resource section for recent literature.
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2. How does burn pain differ from other types of pain, such as a fracture?
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- Usually lasts for more than 1-2 hours, decision point re short vs. long acting analgesia and eventual need for IV access
- Anxiety is a common issue for burn-injured patients, especially in pediatric cases
- Tissue destruction and activation of a cytokine-mediated inflammatory response leads to variable pharmacokinetics
- May need higher doses or a combination of analgesics
- Burn pain is one of the most difficult to treat etiologies of acute pain
- Interventions associated with pain: dressing changes, excision/grafting, etc.
- Good pain control is linked to better wound healing, sleep, participation in activities of daily living, quality of life and recovery
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3. Why is acute pediatric pain management garnering national attention?
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What we do during a child’s first painful experience has lasting effects!
Early acute pain management provides long-term benefits:
- decreased long-term sequela in children
- prevention of chronic pain through the development of hypersensitized pain pathways
- uncontrolled acute pain has links to development of PTSD/PTSS and if inadequately treated can lead to chronic pain, depression, sleep disorders, etc.
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CASE PROGRESSION:
- IN fentanyl was quickly administered while IV set up was prepared and IV access obtained
- Pain decreased allowing for more effective evaluation. FLACC score = 5
- Nonpharmacologic distraction techniques and therapeutic language were used to further calm child, mother and providers
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Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures
Intranasal fentanyl for the prehospital management of acute pain in children
Pharmacologic Management of Acute Pain by EMS in the Prehospital Setting
ENA Clinical Practice Guideline: Intranasal Medication Administration
Practical Pain Management: Intranasal Ketamine for Acute Pain in Children
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An upcoming PEDReady PE
2
ARL will focus on nonpharmacologic pain management and resources.
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PEDReady Champion of the Week
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Guess who is preparing their EMT and paramedic students to be PEDReady this week?
Shout out to
Tom McCrone, MPA
, Professor and Faculty Director of EMS Programs at
Florida State College-Jacksonville, North Campus
! The program is utilizing Florida EMSC/PEDReady materials and equipment such as our new
Scenarios in Seconds
Training Kit and “Nickie,” our Special Needs Training Manikin.
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Upcoming Pediatric Emergency Conferences
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CLINCON 2019
July 17–19, 2019 |
Orlando, FL
Hosted by: EMLRC
Designed for the entire spectrum of emergency care providers. General conference lectures include
The Pregnant Patient Skills Lab, Tips & Tricks for Blue & Barely Breathing Baby
and more!
Access Brochure
Pre-Con Workshop:
Managing Pediatric Cardiac Arrest
July 17, 2019 | 8:00-12:00 pm
Florida EMSC Advisory Committee Meeting
July 17, 2019 | 1:00 pm
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Symposium by the Sea 2019
August 1-4, 2019 | Boca Raton, FL
Hosted by: Florida College of Emergency Physicians (FCEP)
FCEP's annual meeting & educational conference, Symposium by the Sea, is designed for emergency physicians, residents, students, physician assistants, nurses and allied health professionals interested in emergency care.
Pediatric Trauma Workshop
August 2, 2019 | 9:00 am to 12:00 pm
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Pediatric Care After Resuscitation (PCAR) Course
Dec 2-3, 2019 | Jacksonville, FL
The mission of TCAR (Trauma Care After Resuscitation) Education Programs is to expand the knowledge base and clinical reasoning skills of nurses who work with injured patients anywhere along the trauma continuum of care, particularly in the post-resuscitation phase.
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Thanks for being a Pediatric Champion!
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The Florida PEDReady Program
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