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Date: June 1st, 2015

Guest Skeptic: Dr. Anthony Crocco is the Division Head and Medical Director of Pediatric Emergency Medicine at McMaster University. He is also known as a RANTer and a SketchEBM kind of guy.

Case: Thirteen year-old boy twists his leg at school. He presents to the emergency department with a laterally displaced patella. Prior to reduction of the dislocated patella, you wonder what you can give the child for pain management.

Background: Oligoanalgesia is defined as the lack of or inadequate pain control. There are many studies showing this is a big problem in the emergency department (Wilson and Pendleton, Motov and Khan). Some groups of patients who are at great risk for oligoanalgesia (elderly, women, mentally ill, certain ethnic groups, and insurance status). Check out this seven minute YouTube video on the subject of oligoanalgesia recorded at CAEP 2015 with a special surprise at 3:37 mark.

There are many options available to treat paediatric pain both pharmacologically (analgesics, NSAIDS, nerve blocks, sub-dissociative dose ketamine and opioids) and non-pharmacologically (distraction, sucrose, infant warmers and splinting). Here are some references for more information on the topic of paediatric pain:

Cimpello LB et al. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care 2004

Kircher J et al. Pediatric musculoskeletal pain in the emergency department: A medical record review of practice variation. CJEM 2014

Poonai N et al. Opiod analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med 2014

Harman S et al. Efficacy of pain control with topical lidocaine-epinephprine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial. CMAJ 2013

Stevens B et al. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane 2013

Gray L et al. Sucrose and warmth for analgesia in healthy newborns: an RCT. Pediatrics 2015

Hartling L et al. Music to reduce pain and distress in the pediatric emergency department: a randomized clinical trial. JAMA Pediatr 2013

Tanabe P et al. The effect of standard care, ibuprofen, and distraction on pain relief and patient satisfaction in children with musculoskeletal trauma. J Emerg Nurs 2002

To see a YouTube video on paediatric pain management in the Emergency Department checkout RANThony#3…Don’t be Dr. Evil, manage paediatric pain well. Other RANThonys by Dr. Crocco include Fever Fear and Paediatric Cough Medications.

Question: Can intranasal fentanyl be used in paediatric patients in pain to safely help control pain?

Reference: Murphy et al. Intranasal fentanyl for the management of acute pain in children. Cochrane 2014

Population: Randomized control trials (RCTs) and quasi RCTs studying children in acute pain

Randomized control trials (RCTs) and quasi RCTs studying children in acute pain Intervention : Intranasal fentanyl

: Intranasal fentanyl Comparison: Any other pharmacological/non-pharmacological intervention

Any other pharmacological/non-pharmacological intervention Outcome: Primary Outcome: Reduction in pain score Secondary Outcomes: Adverse events, tolerance, rescue analgesia use, satisfaction of parent/patient, cost and mortality



Authors’ Conclusions: “Intranasal fentanyl (INF) “may be an effective analgesic for the treatment of patients with acute moderate to severe pain, and its administration appears to cause minimal distress to children.”

Quality Checklist for Therapeutic Systematic Reviews:

The clinical question is sensible and answerable. Yes . This is a really important question. In children with pain, it would be very helpful to have a safe, effective and quick way to treat moderate to severe pain. The search for studies was detailed and exhaustive. Yes The primary studies were of high methodological quality. Yes The assessment of studies were reproducible. Yes The outcomes were clinically relevant. Yes There was low statistical heterogeneity for the primary outcomes. No The treatment effect was large enough and precise enough to be clinically significant. Yes

Key Results: Three studies were included in this systematic review. One study compared intranasal fentanyl to intramuscular morphine, another intranasal fentanyl to intravenous morphine and the last compared intranasal fentanyl given in two different concentrations. Given these methodological differences, combining data sets was not possible.

When intranasal fentanyl was compared to intramuscular morphine, intranasal fentanyl was found to have no significant difference in pain control, except at 10 minutes when intranasal fentanyl had a lower pain score (p<0.014). When intranasal fentanyl was compared to intravenous morphine, there were no significant differences noted in pain reduction between groups.

No adverse events or deaths were noted in any of the studies. There was one participant who experienced a bad taste and another who vomited from the intranasal fentanyl group. In comparison, one patient in the intravenous morphine group experienced flushing of the IV site.

This is a really well performed systematic review. The search strategy was thorough and the included studies, albeit not many, were of good quality.

Sadly, all three studies were so different in their methodology, that their data could not be combined.

All three studies point towards intranasal fentanyl being an effective and safe method of managing moderate to severe paediatric pain.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: Agree 100%

SGEM Bottom Line: For children with acute moderate to severe pain, using intranasal fentanyl is a safe and effective way to manage the pain.

Case Resolution: This child is administered intranasal fentanyl and shortly after a reduction of the child’s dislocated patella.

Clinically Application: In children with acute moderate to severe pain, intranasal fentanyl can be used safely to manage their pain.

What Do I Tell My Patient? We are going to spray some medicine in your nose and this will help reduce your pain.

Keener Kontest: Last weeks winner was Claudia Martin. Claudia knew the passage below or behind a tier of seats in a stadium through which crowds can exit is called a vomitorium.

Listen to the podcast for this weeks keener question. If you know the answer send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct response will win a cool skeptical prize.