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PAMI Pain Mangement and Dosing Guide 02282017
PAMI Pain Mangement and Dosing Guide 02282017
PAMI Pain Mangement and Dosing Guide 02282017
Principles of Pain Management Pain Management Considerations Analgesic Ladder and Treatment Basics
• Type of pain: nociceptive, neuropathic, inflammatory
Establish realistic pain goals • Acute vs. chronic vs. acute on chronic pain exacerbation Step 3: Severe Pain
Will vary depending on patient and type of • Pain medication history: OTC, Rx and herbal Step 1 and Step 2 Strategies +/- Scheduled
• Patient factors: genetics, culture, age, previous Opioid Analgesics
pain - goal of zero may not be feasible
pain experiences, comorbidities
• Verify dosing for < 6 mo and > 65 yo
Treatment Options
Educate patient/caregivers on pain • Pharmacotherapy: systemic, topical, transdermal - Step 2: Moderate Pain
management goals and regimen nerve blocks Step 1 Strategy + Intermittent Dose of Opioid
• Non-pharmacologic modalities Analgesics (PO, IV) +/-
• Refer to pain, palliative or other specialists for Interventional (Blocks & Procedures)
advanced treatment
Consider pharmacologic and Non-pharmacological modalities
non-pharmacologic treatment options and Splinting, distraction, hot/cold therapy, Step 1: Mild Pain
initiate therapy exercise, massage, imagery, and others Non-opioid Analgesic (APAP, NSAIDs, COX-2
Inhibitors) +/- Local/Topical Anesthetics
Discharge and Patient Safety Considerations
• Assess and counsel regarding falls, driving, work
safety, and medication interactions Ladder Basics
Continually reassess patient’s pain • Bowel regimen for opioid induced constipation 1. Use oral route when possible
and monitor for medication efficacy and • Vital signs and oral intake before discharge 2. Give analgesics at regular intervals
side effects • Document all pain medications administered and 3. Prescribe according to pain intensity
response at time of discharge or disposition
• Use same scale to reassess pain • Consider OTC and non-pharmacologic options
4. Dosing must be adapted to individual
• Use scale that is age and cognitively appropriate • Can patient implement pain management plan? 5. Analgesic plan must be refined and
• If no improvement, adjust regimen - insurance coverage, transportation, etc. communicated with patient and staff
Minor cuts, scrapes, burns, Externally 3-4 times per day. Apply in area less
Lidocaine 4% (L.M.X.4®) sunburn, insect bites, and minor O: 20-30 min Apply externally than 100cm2 for children less than 10kg. Apply
skin irritations D: 60 min in area less than 600cm2 for children between
10 and 20kg
LET (Lidocaine Epinephrine Tetracaine) O: 10 min Topical 3 mL
(gel or liquid) Wound repair (non-mucosal) D: 30-60 min 4% Lidocaine, 1:2,000 Epinephrine, 0.5% Tetracaine (not to exceed maximal Lidocaine
dosage of 3-5 mg/kg)
EMLA (2.5% Lidocaine 2.5% Prilocaine) O: 60 min 3-12 mo (>5 kg): 2 gm 3-12 mo max area 20cm2
Cover with occlusive dressing Dermal analgesic (intact skin) D: 3-4 h 20 gm 1-6 yo (>10kg): 10 gm 1-6 yo max area 100cm2
Maximum application time 4 hours 7-12 yo (>20kg): 20 gm 7-12 yo max area 200cm2
Pain-Ease® Cooling intact skin and mucus O: immediate Spray for 4-10 sec from distance
Vapocoolant/Skin Refrigerant membranes and minor open D: few sec to — of 8-18 cm. Stop when skin turns white to avoid frostbite
wounds 1 min Not recommended for < 3 yo
Foley catheter and nasogastric O: 2-5 min 2% topical gel/jelly, 5% topical ointment, 2% oropharyngeal
Lidocaine tube insertion; intubation; nasal D: 30-60 min viscous topical solution 3-5 mg/kg
packing; gingivostomatitis
*Dosages are guidelines to avoid systemic toxicity in patients with normal intact skin and with normal renal and hepatic function