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## Complete Summary

#### GUIDELINE TITLE

Relief of pain and anxiety in pediatric patients in emergency medical
systems.

#### BIBLIOGRAPHIC SOURCE(S)

Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients
in emergency medical systems. Pediatrics 2004 Nov;114(5):1348-56. \[143
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15520120)

#### GUIDELINE STATUS

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years
by the authoring body, at which time a recommendation is made that the
policy be retired, revised, or reaffirmed without change. Until the
Board of Directors approves a revision or reaffirmation, or retires a
statement, the current policy remains in effect.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

On April 7, 2005, after concluding that the overall risk versus benefit
profile is unfavorable, the FDA requested that Pfizer, Inc voluntarily
withdraw Bextra (valdecoxib) from the market. The FDA also asked
manufacturers of all marketed prescription nonsteroidal
anti-inflammatory drugs (NSAIDs), including Celebrex (celecoxib), a
COX-2 selective NSAID, to revise the labeling (package insert) for their
products to include a boxed warning and a Medication Guide. Finally, FDA
asked manufacturers of non-prescription (over the counter \[OTC\])
NSAIDs to revise their labeling to include more specific information
about the potential gastrointestinal (GI) and cardiovascular (CV) risks,
and information to assist consumers in the safe use of the drug. See the
[FDA Web
site](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#Bextra) for
more information.

Subsequently, on June 15, 2005, the FDA requested that sponsors of all
non-steroidal anti-inflammatory drugs (NSAID) make labeling changes to
their products. FDA recommended proposed labeling for both the
prescription and over-the-counter (OTC) NSAIDs and a medication guide
for the entire class of prescription products. All sponsors of marketed
prescription NSAIDs, including Celebrex (celecoxib), a COX-2 selective
NSAID, have been asked to revise the labeling (package insert) for their
products to include a boxed warning, highlighting the potential for
increased risk of cardiovascular (CV) events and the well described,
serious, potential life-threatening gastrointestinal (GI) bleeding
associated with their use. FDA regulation 21CFR 208 requires a
Medication Guide to be provided with each prescription that is dispensed
for products that FDA determines pose a serious and significant public
health concern. See the [FDA Web
site](http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#NSAID) for
more information.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Pain and/or stress that is caused by a disease process, a result of
acute injury, or a product of a diagnostic or therapeutic procedure

#### GUIDELINE CATEGORY

Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Emergency Medical Technicians/Paramedics\
Nurses\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To provide information to optimize the comfort of children whether they
are cared for in the emergency setting or other environments

#### TARGET POPULATION

Children who enter into the emergency medical system

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation/Management**

1.  Non-pharmacological or stress management and emotional support via
    friendly, calming environment, distraction techniques, child life
    specialists, and family presence

2.  Pain assessment

    -   Self-report scales (Wong-Baker Faces Scale; 10-cm Visual Analog
        Scale)

    -   Behavioral scales in combination with an evaluation of
        patient\'s history and physical findings

3.  Triage patients

**Treatment**

*Minor Procedures*

1.  Acetaminophen

2.  Ibuprofen

3.  Oral opiates

4.  Topical anesthetics

    -   Eutectic mixture of local anesthetics (EMLA)

    -   Liposomal 4% lidocaine cream (LMX~4~)

    -   Lidocaine iontophoresis

    -   Vapocoolant sprays

    -   Lidocaine, epinephrine, tetracaine (LET)

5.  Tissue adhesives

    -   Octyl cyanoacrylate

    -   Steri-Strips

6.  Lidocaine (injected)

*Neonatal Pain Management in the Emergency Department (ED)*

1.  EMLA

2.  Sucrose

3.  Pacifier alone or with sucrose

4.  Skin-to-skin contact of mother to infant

5.  Local and topical anesthesia for lumbar puncture

6.  Elimination of heel sticks and intramuscular injection

*Administration of Pain Medications*

1.  Adjunctive pain medications (e.g., nonsteroidal anti-inflammatory
    drugs \[NSAIDs\])

2.  Consideration of alternative routes including oral, intranasal,
    transdermal, and inhaled

3.  Nitrous oxide

4.  Appropriate pain medication on discharge

*Sedation*

1.  Sedative hypnotic medication

2.  Development of policies for close monitoring of patients receiving
    sedation

#### MAJOR OUTCOMES CONSIDERED

-   Efficacy of intervention strategies in minimizing pain and anxiety
    and promoting comfort

-   Safety of medication used to manage pain and anxiety

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Informal Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**[Triage Oral Analgesic Administration Guidelines]{.underline}**

**Purpose**

To provide analgesic therapy to patients presenting to triage with a
complaint of pain

**Procedure**

1.  Pain assessment

2.  Immediate triage to department for all those with severe pain as
    assessed by triage nurse and consideration of pain score

3.  For those not requiring immediate evaluation with pain score \>3
    (0-10 scale) or chief complaint consistent with pain, consider
    administration of oral analgesic

4.  Assess recent analgesic use

**Contraindications**

1.  Allergy to analgesic (consider alternative)

2.  Nothing by mouth (NPO) status (if patient may require procedural
    sedation or general anesthesia, consult with a physician before
    analgesic administration)

**Medications**

1.  Ibuprofen (avoid if the patient has an aspirin allergy, anticipated
    surgery, bleeding disorder, hemorrhage, or renal disease)

2.  Acetaminophen (avoid if the patient has hepatic disease or
    dysfunction)

3.  Acetaminophen with codeine or other oral opiate

**[Guidelines for the Use of Eutectic Mixture of Local
Anesthetics/Liposomal 4% Lidocaine Cream (EMLA/LMX~4~) in the Emergency
Department (ED)]{.underline}**

EMLA/LMX~4~ use should be considered in any patient who has a high
likelihood of undergoing a nonemergent invasive procedure on intact skin
in the ED. These include:

-   Intravenous line placement or venipuncture

-   Lumbar puncture

-   Abscess drainage

-   Joint aspiration

Discussion with parents should bring up these issues:

-   EMLA/LMX~4~ does not provide complete pain relief

-   Some patients may require a procedure before EMLA/LMX~4~ reaches its
    full effectiveness (see below)

**Contraindications**

-   Emergent need for intravenous access

-   Allergy to amide anesthetics

-   Nonintact skin

-   Recent sulfonamide antibiotic use (trimethoprim-sulfamethoxazole,
    erythromycin-sulfisoxazole) (EMLA only)

-   Congenital or idiopathic methemoglobinemia (EMLA only)

The EMLA dose should be lower for patients \<12 months old or weighing
\<10 kg

**Placement of EMLA/LMX~4~**

-   Intravenous line placement

    -   EMLA/LMX~4~ should be placed in at least 2 sites over veins
        amenable to placement of an intravenous line as judged by the
        triage nurse.

    -   EMLA reaches full effectiveness in 1 h; LMX~4~ reaches full
        effectiveness in 30 min.

    -   Care should be taken to avoid mucous membrane contact or
        ingestion.

-   Lumbar puncture

    -   Placement of EMLA/LMX~4~ for lumbar puncture should be
        considered at triage; accurate placement requires consultation
        with the attending physician.

**[Triage Guidelines for use of Lidocaine, Epinephrine, Tetracaine (LET)
(a Topical Anesthetic for Open Wounds]{.underline}**

**Eligibility**

-   Simple lacerations of the head, neck, extremities, or trunk \<5 cm
    in length

**Contraindications**

-   Allergy to amide anesthetics

-   Gross contamination of wound

-   Involvement of mucous membranes, digits, genitalia, ear, or nose

**Procedure**

-   LET should be placed according to standard ED procedure; time of
    placement should be documented on triage sheet.

-   Maximum wound length: 5 cm; maximum dose: 3 mL

> \(1\) Place 3 mL of LET mixed with cellulose on open wound and cover
> with occlusive dressing or (2) place cotton ball soaked with LET
> solution into wound

**[Guidelines for the Use of Sucrose in the ED]{.underline}**

**Indications**

-   Use as an adjunct for limiting the pain associated with procedures
    such as heel sticks, venipuncture, intravenous line insertion,
    arterial puncture, insertion of a Foley catheter, and lumbar
    puncture in neonates and infants younger than 6 months.

**Procedure**

1.  Administer 2 mL of 25% sucrose solution by syringe into the
    infant\'s mouth (1 mL in each cheek) or allow infant to suck
    solution from a nipple (pacifier) no more than 2 min before the
    start of the painful procedure.

2.  Sucrose may be given for \>1 procedure within a relatively short
    period of time but should not be administered more than twice in 1
    hour.

3.  Sucrose seems to be more effective when given in combination with a
    pacifier; nonnutritive suck also contributes to calming the infant
    and decreasing pain-elicited distress.

**Contraindications**

-   Avoid use if patient is under NPO restrictions.

**[Summary of Key Points]{.underline}**

1.  Training and education in pediatric pain assessment and management
    should be provided to all participants in emergency medical systems
    for children.

2.  Simple methods for creating favorable environmental conditions for
    pediatric patients in the emergency medical services (EMS) setting
    should be advocated by caregivers.

3.  Incorporation of child life specialists and others trained in
    nonpharmacologic stress reduction should be encouraged.

4.  Family presence should be offered as an option during painful
    procedures.

5.  Pain assessment for children should begin at admission to EMS and
    continue until discharge from the ED. On discharge, patients should
    receive detailed instruction regarding analgesic administration.

6.  Painless administration of analgesics and anesthetics should be
    practiced when possible.

7.  Neonates and young infants should receive appropriate pain relief.

8.  Administration of pain medication has not been shown to hinder the
    evaluation of a possible surgical patient in the ED, and pain
    medication should not be withheld on this account.

9.  Sedation should be provided for patients undergoing painful or
    stressful procedures in the ED. A structured protocol for pediatric
    sedation, based on American Academy of Pediatrics (AAP), American
    Society of Anesthesiologists (ASA), American College of Emergency
    Physicians, and Emergency Medical Services for Children
    recommendations, should be followed for all children who receive
    sedative medications in EMS.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting each recommendation is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Adequate pain assessment

-   Control of pain and stress and optimization of comfort for children
    who enter into the emergency medical system

#### POTENTIAL HARMS

-   Approximately 5% of children find the sensation caused by
    iontophoretic drug delivery to be unpleasant.

-   Nonsteroidal anti-inflammatory drugs have the following known side
    effects: antiplatelet activity and gastrointestinal and renal
    toxicity.

-   Combinations of medications, particularly the addition of opiates to
    sedative medications, may increase the risk of respiratory
    depression and should only be used by individuals trained in airway
    management and resuscitation.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

**Analgesic Therapy**

-   Allergy to analgesic (consider alternative)

-   Nothing by mouth (NPO) status (if patient may require procedural
    sedation or general anesthesia, consult with a physician before
    analgesic administration)

**Eutectic Mixture of Local Anesthetics/Liposomal 4% Lidocaine Cream
(EMLA/LMX~4~)**

-   Emergent need for intravenous access

-   Allergy to amide anesthetics

-   Nonintact skin

-   Recent sulfonamide antibiotic use (trimethoprim-sulfamethoxazole,
    erythromycin-sulfisoxazole) (EMLA only)

-   Congenital or idiopathic methemoglobinemia (EMLA only)

**Lidocaine, Epinephrine, Tetracaine (LET)**

-   Allergy to amide anesthetics

-   Gross contamination of wound

-   Involvement of mucous membranes, digits, genitalia, ear, or nose

**Nitrous Oxide**

-   Nitrous oxide should be avoided in patients with pneumothorax, bowel
    obstruction, intracranial injury, and cardiovascular compromise.

**Sucrose**

-   Avoid use if patient is under NPO restrictions

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients
in emergency medical systems. Pediatrics 2004 Nov;114(5):1348-56. \[143
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15520120)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Nov

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Committee on Pediatric Emergency Medicine\
Section on Anesthesiology and Pain Medicine

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Authors*: William T. Zempsky; Joseph P. Cravero

*Committee on Pediatric Emergency Medicine, 2003-2004*: Jane F. Knapp,
MD, *Chairperson*; Thomas Bojko, MD; Margaret A. Dolan, MD; Karen S.
Frush, MD; Ronald A. Furnival, MD; Steven E. Krug, MD; Daniel J.
Isaacman, MD; Robert E. Sapien, MD; Kathy N. Shaw, MD, MSCE; Paul E.
Sirbaugh, DO

*Liaisons*: Jane Ball, RN, DrPH, EMSC National Resource Center; Kathleen
Brown, MD, National Association of EMS Physicians; Dan Kavanaugh, MSW,
Maternal and Child Health Bureau; Sharon E. Mace, MD, American College
of Emergency Physicians; David W. Tuggle, MD, American College of
Surgeons

*Staff*: Susan Tellez

*Section on Anesthesiology and Pain Medicine, 2003--2004*: Thomas J.
Mancuso, MD, *Chairperson*; Joseph P. Cravero, MD, *Chairperson-elect*;
Rita Agarwal, MD; Constance S. Houck, MD; Zeev Kain, MD; Lynne G.
Maxwell, MD; Robert D. Valley, MD, *Immediate Past Chairperson*;
Patricia J. Davidson, MD

*Liaison*: Carolyn Fleming Bannister, MD, American Society of
Anesthesiologists, Committee on Pediatrics

*Staff*: Kathleen Kuk Ozmeral

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years
by the authoring body, at which time a recommendation is made that the
policy be retired, revised, or reaffirmed without change. Until the
Board of Directors approves a revision or reaffirmation, or retires a
statement, the current policy remains in effect.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Policy Web
site](http://pediatrics.aappublications.org/cgi/content/full/114/5/1348).

Print copies: Available from American Academy of Pediatrics, 141
Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on January 11, 2005. The
information was verified by the guideline developer on February 10,
2005. This summary was updated on May 3, 2005 following the withdrawal
of Bextra (valdecoxib) from the market and the release of heightened
warnings for Celebrex (celecoxib) and other nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration advisory
on COX-2 selective and non-selective non-steroidal anti-inflammatory
drugs (NSAIDs).

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest
Point Blvd, Elk Grove Village, IL 60007.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008