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ANALGESIA

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ANALGESIA IS THE DIMINUTION OR ELIMINATION OF PAIN IN THE CONSCIOUS PATIENT.

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  • Even neonates demonstrate behavioral and hormonal changes in response to painful procedures

  • Children do not have to understand the meaning of pain nor do they have to communicate pain to experience pain

  • Preemptive analgesia may decrease post-injury opioid requirements

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ASSESSMENT OF PAIN

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  • Observational-behavioral measures

    • ✓ Useful in infants and toddlers (who do have physiologic and behavioral responses to pain, such as increased heart rate, blood pressure, respiratory rate, crying, flushing, facial expressions, and body movements)

    • ✓ Example: FLACC (Face, Leg, Activity, Cry, Consolability) Behavioral Pain Scale (Merkel SI, et al. The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatr Nurs. 1997;23(3):293–297)

  • Self-report

    • ✓ OUCHER scale combines numeric and faces scales, making it appropriate for young children (available at http://www.oucher.org)

    • Faces scale: The child is asked to point to the face that best describes his/her own pain (available at http://www.wongbakerfaces.org)

    • Verbal numeric pain rating: Useful in developmentally normal children 6–7 years of age (or older). Pain is rated from 0 to 10 (0 is no pain and 10 is the worst pain imaginable)

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LOCAL ANESTHESIA

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EUTECTIC MIXTURE OF LOCAL ANESTHETICS (EMLA)

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  • 2.5% Lidocaine/2.5% Prilocaine

  • Apply to intact skin; complete anesthesia in 60–90 minutes

  • Use for blood drawing/IV placement, bone marrow aspiration, lumbar puncture in non-emergent settings

  • May use liposomal lidocaine (LMX) for faster onset; topical lidocaine only; anesthesia in 30 minutes

  • Contraindications: Methemoglobinemia, age less than 1 month

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LIDOCAINE, EPINEPHRINE, TETRACAINE (LET)

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  • Used for dermal lacerations; apply to open wound

  • Contraindicated in areas supplied by end-arteries (digits, pinna, nose, penis)

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VISCOUS LIDOCAINE

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  • For older children who can expectorate

  • Combine with diphenhydramine and Maalox in equal parts (1:1:1) to create “magic mouthwash” (can also exclude lidocaine if mouth sores create a concern for systemic absorption)

  • Usual dose: 15 mL of undiluted mixture to “swish and spit” (not swallow); maximum dose is 4.5 mg/kg or 300 mg of lidocaine component (up to every 3 hours). Smaller amounts work well

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LIDOCAINE JELLY

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  • Used for nasogastric tube placement and urethral catheterizations

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INJECTABLE LOCAL ANESTHETIC

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  • Buffer with 1 mL (1 mEq/mL) sodium bicarbonate (NaHCO3) per 9 mL lidocaine or 0.1 mL NaHCO3 per 10 mL bupivacaine to reduce pain associated with injection

  • Enhance efficacy and duration by using in combination with epinephrine

  • Contraindicated in areas supplied by end arteries (digits, pinna, nose, penis)

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NARCOTIC ANALGESICS

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  • All doses referred to here are equianalgesic doses

  • All opioids can be reversed with naloxone hydrochloride (Narcan) 0.01 mg/kg IV/IM/SC/ETT; naloxone can be repeated every 2 minutes as needed to maximum of 10 ...

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