Page 393 Acute Pain Management

Level II), oral hydromorphone, morphine and oxycodone reduced pain associated with dressing
changes (Sharar et al, 1998 Level II; Sharar et al, 2002 Level II).
Non‐pharmacological strategies such as distraction, preparation, parental presence and
hypnosis may be effective. Music (Fratianne et al, 2001 Level II), virtual reality games (Das et al,
2005 Level II) and massage therapy (Hernandez‐Reif et al, 2001 Level IV) reduced self‐reported
pain scores associated with burn dressing changes.

10.4.3 Immunisation pain in infants and children
Procedure modifications, such as rapid injection and needle withdrawal (Ipp et al, 2007 Level II)
and using a longer needle (Schechter et al, 2007 Level I) reduced pain associated with
immunisations. Parental responses during injection such as excessive reassurance, criticism or
apology increase distress, whereas humour and distraction tend to decrease distress (Schechter
et al, 2007 Level I).
Oral sucrose in infants aged 2 to 4 months or breastfeeding in neonates reduced the duration
of pain behaviour after but not during immunisation (Efe & Ozer, 2007 Level II; Hatfield, 2008
Level II). Combining sucrose, oral tactile stimulation and parental holding reduced the duration
of crying in infants receiving multiple vaccinations (Reis et al, 2003 Level II). Combination of
EMLA® and oral glucose reduced the behavioural and physiologic response to immunisation
(Lindh et al, 2003 Level II).
Selective use of topical local anaesthetic has been recommended in older children (Schechter
et al, 2007 Level I) and the combination of topical EMLA®, preparation, parental presence and
distraction reduced pain scores during immunisation in 4 to 12 year old children (Boivin et al,
2008 Level III‐1).

10.4.4 Procedural pain management in the emergency department
Laceration repair
Topical anaesthesia for wound closure can avoid the distress caused by intradermal injection
of local anaesthetic, but cocaine‐containing preparations are no longer recommended
(Eidelman, Weiss, Enu et al, 2005). Topical anaesthetics, such as lignocaine‐adrenaline‐
amethocaine solutions were safe and effective in children (Schilling et al, 1995 Level II; Smith et al,
1997 Level II; White et al, 2004 Level III‐1), and had equivalent or superior efficacy when
compared with intradermal administration (Eidelman, Weiss, Enu et al, 2005 Level I). Application
of topical anaesthetic solution to wounds at triage reduced treatment time (31 minutes less
than controls) (Priestley et al, 2003 Level II) and reduced pain associated with subsequent CHAPTER 10
intradermal injection of lignocaine (Singer & Stark, 2000 Level II). Topical anaesthesia reduced
the requirement for procedural sedation for wound management (Pierluisi & Terndrup, 1989
Level III‐3).
Tissue adhesives (Farion et al, 2003 Level I) and hair apposition for scalp lacerations (Hock et al,
2002 Level III‐1) were as effective as suturing for simple lacerations but produced less pain and
may be more acceptable to children.
Inhaled 50% N 2O / 50% oxygen reduced pain and anxiety during laceration repair (Burton et al,
1998 Level II; Luhmann et al, 2001 Level II) in children.
Fracture pain and reduction
In order to provide analgesia rapidly, opioids are increasingly being administered at triage in
children with suspected fractures. To avoid the distress associated with IV access or IM
injections, alternative routes of opioid delivery have been investigated in the emergency
department. IN diamorphine (Kendall et al, 2001 Level III‐1) and fentanyl via IN (Borland et al,
Acute pain management: scientific evidence 345