Pediatric Pain Management in an Anti-Opioid Environment: Challenges and Resources · 2018-09-18 ·...

Pediatric Pain Management in an Anti-Opioid Environment Challenges and Resources

Phyllis L Hendry MD FAAP FACEP

Term Professor of Emergency Medicine and Pediatrics

Assistant Chair for Research Dept of Emergency Medicine

University of Florida College of MedicineJacksonville

Trauma One Deputy Medical Director Pediatric Transport

PI Pain Assessment and Management Initiative (PAMI)


Pediatric Pain Management in an Anti-Opioid Environment

Challenges and Resources

FINANCIAL DISCLOSUREI have no relationship with a

commercial supporter

UNLABELEDUNAPPROVED USES DISCLOSURE None

Learning Objectives

1 Describe a stepwise approach for managing pediatric pain and sedation based on setting situation development and family

2 Identify factors affecting the individual childrsquos response to pain

3 Discuss advantages of using nonpharmacologic pain management techniques and distraction to decrease opioid dosage save time and improve patient safety

4 Describe current societal trends and challenges in pain management

5 Identify pediatric pain management resources and tools

Learning ObjectivesRapidly Changing Landscape

My Background Why Pain

bull Pediatric

bull EM

bull Trauma

bull EMS

bull Hospice and Palliative Care

bull Professional and personal experiences

bull Education grants and research mutidisciplinary

Why Focus on Pain Management

bull Chronic pain alone affects more Americans than diabetes cancer and heart disease combined

bull Pain is the most common reason for seeking health care and as a presenting complaint accounts for up to 78 of ED visits

bull Pain is often undertreated especially in children women African-Americans and Hispanics

bull Trauma accounts for 28 of pediatric EMS calls but lt1 receive pain medications (PECARN)

bull Why donrsquot we treat pain like any other abnormal VS or disease

BP and glucose example

Pain 101-itrsquos complicated

Pain Assessment and Management Initiative (PAMI)

Investigators Phyllis Hendry MD FAAP FACEPSophia Sheikh MD FACEP

Project Manager Raina Davidman LPN EMT MBA

A one-stop free access educational and patient safety project

PAMI mission

Improve pain recognition management and reassessment

Promote opioid stewardship in ED EMS hospital and other settings

Provide learning modules toolkits and resources for providers and patients

2014-present

Presentation includes materials and resources from the

Pain Assessment and Management Initiative (PAMI) a

free access educational project and website Funding

provided by Florida Medical Malpractice Joint Under-

writing Association Alvin E Smith Safety of Health Care

Services Grant All products are multidisciplinary and

designed to be used or adapted by any health care

facility school or agency

httppamiemergencymedjaxufledu

PAMI Stakeholders and Collaborators + Consultants

EMS for Children Program

All PAMI tools amp resources are free access and adaptable

bull 7 Learning Modules with 14 hours of CMECEUs- multidisciplinary

bull Pain Management and Dosing Guide

bull Discharge Planning Toolkit for Pain

bull Patient Educational Videos

bull Distraction-Nonpharmacologic Toolkit-Medical and Pain Communication Cards


PAMI Module Topics-2 hours free CEUCME each

Basics of Pain Management and

Assessment

Pharmacological Treatment of Pain

Non-pharmacological Treatment Management of Acute Pain

Procedural Sedation and Analgesia Pediatric Pain Management

PrehospitalEMS Management of Pain

Pain The Pendulum Swings the Other Way

bull Total upheaval in the world of pain management

bull New research regarding the neurobiological complexity of pain genetics of pain and long term consequences of untreated acute pain

bull Seeing different types of pain due to MVCs and distracted driving sports technology hellip

bull New methods of treating pain

bull Post op nerve blocks

bull Old drugs used in new ways

bull Growth of pain specialists and procedures


bull Opioid addiction epidemic has everyone pointing fingers and outcry for reducing opioids

bull CDC The Joint Commission HCHAPS survey scoring

bull Opioid deaths = MVCs

bull Focus shifting to abusers of the system versus those in real painhow to balance

bull State prescription drug monitoring programs legislation

bull Pain MCI

1Information Management in EHRs

2Unrecognized Patient Deterioration

3Implementation and Use of Clinical Decision

Support

4Test Result Reporting and Follow-Up

5Antimicrobial Stewardship

6Patient Identification

7Opioid Administration and Monitoring in

Acute Care

8Behavioral Health Issues in Non-Behavioral-

Health Settings

9Management of New Oral Anticoagulants

10Inadequate Organization Systems or

Processes to Improve Safety and Quality

2 Patient Safety Concern for 2018 = Opioid Safety Across the Continuum of Care

Challenges- Keeping Balance

bull Rapid influx of new literature

bull Most opioid deaths and ODs are now from nonprescribed or illegalsources

bull Dilemma of balancing safe opioid prescribing and high-risk patient recognition with appropriate pain management strategies for those in significant pain while being mindful of different types of pain individual pain factors and comorbidities

bull Analgesic shortages

bull Multimodal management options

Why Is Pediatric Pain Management So Important

Examples of Common Painful Pediatric Procedures Include

Orthopedic proceduresFx

reduction

Burn amp wound debridement

Cardioversion endoscopy or bronchoscopy

IV or blood drawLumbar

puncture

Chesttube insertion

Radiographic studies in agitated or uncooperative

patients

Abscess incision amp drainage

Laceration repair

Foreign body removal

Other Pediatric Scenarios Requiring Sedation Analgesia andor Anxiolysis

Chronic Pain Conditions

bull Cancerbull Rheumatologic

disordersbull Migraine headaches

Adolescents posing a threat to themselves

or staff

Chronic disorders with an exacerbation or new

painful conditionbull Autism plus procedure

bull Oncology patient with a fracture or abscess

Post-operative pain

bull TonsillectomybullOrthopedic procedures

20

Recurrent pain

Under-treated

pain

Develop-mental factors

Pain memory

Creation of Pain Memory in Children

Coping

Developmental age

Past experience

Temperament

What we do during a childrsquos first painful experience has lasting effects

21

Other Reasons Pediatric Pain Management Important

bull Early management provides long-term benefits

bull decreased long-term sequela in children

bull prevention of chronic pain through the development of hypersensitized pain pathways

bull uncontrolled acute pain link to PTSDPTSS and if inadequately treated can lead to chronic pain depression sleep disorders etc

Sets the trajectory and

tone for future pain

experiences as an

adolescent and adult

hellipmedical training in pain

management is scant

Veterinary schools require

ldquoat least five times more

education on how to handle

painrdquo than medical schools Nora D Volkow the director of the

National Institute on Drug Abuse

said earlier this year in testimony

before a Senate committee

Why Arenrsquot We Managing Childrenrsquos Pain NY Times April 2016

ldquoOne of the best ways to address the

epidemic of chronic pain in this

country is to stop it before it startshellip

If we could reduce painful

experiences in childhood we might be

able to reduce chronic pain in the

next generationrdquo

Chronic Pain in Children Important link between post-traumatic stress amp sleep

Patrick Finan PhD and Melanie Noel PhD

bull Sleep disturbances considered an underlying factor in the co-occurrence of chronic pain and PTSS

bull Chronic pain and sleep are intimately related with strong evidence for a reciprocal association

bull Beyond the influence of demographics and anxiety symptoms sleep quality partially mediates relationships between PTSS and pain intensity and interference

bull Hyperarousal has been linked to increased pain sensitivity pain-related anxiety and pain-avoidant behaviors

Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events (Pediatrics Aug 2018 142 (2) e20172156) C

P Chung MD MPH S T Callahan MD MPH W O Cooper MD MPH et al

METHODS Retrospective cohort study between 1999 and 2014 included TN Medicaid children and adolescents aged 2 - 7 without major chronic diseases prolongedhospitalization institutional residence or evidence of a substance use disorder Weestimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid related adverse events defined as an ED visit hospitalization or deathrelated to an opioid adverse effect

CONCLUSIONS Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute self-limited conditions One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (712 of which were related to therapeutic use of the prescribed opioid)

Editorial The National Opioid Epidemic and the Risk of Outpatient Opioids in Children

Krane EJ Weisman SJ Walco GA Pediatrics 2018 142(2)e20181623hellip know that opioids are associated with many untoward side effects and are potentially lethalhellipbelieve there is a reason why opioids have been used to treat pain since the Sumerians 5000 years ago no other analgesics equal in potency and effect have been discovered to reduce sufferinghellipstaunch advocates for need to provide adequate treatment of pain and suffering after surgeries burns physical trauma and medical illnesses such as sickle cell cancer CDC reports ldquoopioid-related deaths rdquo deaths that occur with opioids in the blood without any other attribution for the cause of deathhellip better called the ldquopolypharmacy overdose epidemic rdquoscant evidence to support existence of an epidemic of deaths due to the appropriate use of prescribed opioids

Pediatric ED Pain Scenarios- Huge Spectrum

bull A 6 yo sickle cell patient in Florida on vacation- presents in severe pain despite trying usual pain plan and medications

bull A 14 yo presents with JRA and severe joint pain

bull A 5 yo presents after fall off monkey bars with obvious deformity of arm

bull An irritable 6 month old presents with a huge abscess and fever

bull A 3 yo presents with burns after pulling pot of boiling water off the stove

28

Cases I am seeing nowbull 2 yo child of a health care provider

severe dog bite to face and lip Refuses sedation or pain meds due to concern for addiction

bull 15 yo positive for suicidal ideation and cutting on triage screening Having joint and generalized pain for months Ibuprofen and acetaminophen do not work Mother desperate and taking her for acupuncture without the PCP or Fatherrsquos knowledge

bull Mother demanding Rx for fentanyl patches for her sons ankle sprain

First Step is Recognition and Assessment of Pediatric Pain

The First Step is to Recognize or Anticipate a Painful Condition

bull Children often cannot differentiate between pain and anxiety

bull The childrsquos demonstration of pain and response to pain is multifactorial and related to age or developmental stage

bull Procedures and treatments used to manage the disease or injury may induce pain

31

Factors Affecting Pediatric Response to Painful Stimuli

bull Age gender ethnicity

bull Socioeconomic and psychiatric factors

bull Culture and religion

bull Genetics

bull Previous experiences

bull Patientfamily perceptions

32

Elements of Pain Assessment

Assess physiologic parameters

Perform behavioral

observation

Question the child

Use standardized assessment

tool

33

Consider

bull The childrsquos primary language

bull Words or phrases suggested by the parentcaregiver

bull The childrsquos developmental level

Explore

bull Location of pain

bull Duration of pain

bull Quality of pain

bull Precipitating factors

bull Effect on daily activities

bull Pain relief measures

bull Previous pain experiences


Perform behavioral

observation

Question the child

Use standardized

assessment tool

34

There are numerous mnemonics on how to obtain pain history OPQRST SOCRATES and QISS TAPED

OPQRSTO ndash Onset of event

bull What was the patient doing when it started Were they active inactive and or stressed

bull Did that specific activity prompt or start the onset of pain bull Was onset of pain sudden gradual or part of an ongoing chronic

problem

P - Provocation and palliation of symptoms bull Is the pain better or worse with

bull Activity Does walking standing lifting twisting reading etchellip have any effect of the painbull Position Which position causes or relieves pain Provide examples to the patient-- sitting

standing supine lateral etchellip bull Adjuvant Which type of medication relieves the pain (Tylenol Ibuprofen etc ) Does the use of

heat or ice packs alleviate pain What type of alternative therapy (massage acupuncture) have you used before

bull Does any movement pressure (such as palpation) or other external factor make the problem better or worse This can also include whether the symptoms relieve with rest

35

36

Pain Assessment SOCRATES

Site - Where is the pain Or the maximal site of the pain

Onset - When did the pain start and was it sudden or gradual Include also whether if it is progressive or regressive

Character - What is the pain like An ache Stabbing

Radiation - Does the pain radiate anywhere (See also Radiation)

Associations - Any other signs or symptoms associated with the pain

Time course - Does the pain follow any pattern

ExacerbatingRelieving factors - Does anything change the pain

Severity - How bad is the pain

What are Some Reasons A Child or Adolescent Might Not Disclose Their Pain

37

Why Children Might Not Disclose Pain

bull Avoidance of painful treatments

bull Fear of being sick

bull Fear of healthcare professionals

bull Protection of parents or caregiver

bull Avoidance of hospitalization

bull Desire to return to activitiesbull Sportsbull Social eventsbull School

38

Choose an appropriate tool based on the childrsquos

bull Age

bull Cognitive ability and language

bull Condition

bull Institutional preference

bull Use the same pain scale throughout the EMSEDhospital experience

bull Educate the childparentcaregiver about the use of the scale

39


Perform behavioral

observation

Question the child

Use standardized

assessment tool

Pain Assessment Scales

bull Pain scales fall into 2 general categories

bull Observational-behavioral scales require provider to assess patient on multiple behaviors and rank them

bull Self-report scales include selection of a face or color or number to represent pain

40

bull There are different validated pain

scales available for a variety of patient populations

Pain Scales Verbal Alert and Oriented Non-verbal GCS lt15 or Cognitive Impairment

Adult 1 Verbal Numeric Scale (VNS) Numeric Rating Scale (NRS)

2 Visual Analogue Scale (VAS)3 Defense and Veterans Pain

Rating Scale (DVPRS)

1 Adult Non-Verbal Pain Scale (NVPS)2 Assessment of Discomfort in Dementia (ADD)3 Behavioral Pain Scale (BPS)4 Critical-Care Observation Tool (CPOT)

Pediatric 3 yo and older1 Wong Baker Faces 2 Oucher (3-12yrs)3 Numerical Rating Scale (NRS)

(7-11yrs)8 yo and older

1 Visual Analogue Scale (VAS)2 Verbal Numeric Scale (VNS)

Numeric Rating Scale (NRS)

Birth ndash 6 mos1 Neonatal Infant Pain Scale (NIPS)2 Neonatal Pain Assessment and Sedation Scale (N-PASS)3 Neonatal Facial Coding System (NFCS) 4 CRIES

Infant and older1 Revised Faces Legs Activity Cry and Consolability

(r-FLACC)2 Non Communicating Childrenrsquos Pain Checklist (NCCPC-R)3 Childrenrsquos Hospital of Eastern Ontario Pain Scale (CHEOPS)

(ages 1-7)

Examples of Pain Scales

41This is a short list of pain scales Determine which pain assessment tools are used by your agency or facility

Pediatric Non-verbal GCS lt15 or Cognitive Impairment

42

Pediatric Verbal Alert and Oriented

43

Pediatric or Adult Verbal Alert and Oriented

44

45

Ann Emerg Med 2018 Jun71(6)691-702

Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain

Tsze DS1 von Baeyer CL Pahalyants V Dayan PSSTUDY OBJECTIVE The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity It is unclear how the validity and reliability of the scale scores vary across childrens ages We aimed to determine the validity and reliability of the scale for children presenting to the ED across a comprehensive spectrum of ageMETHODS This was a cross-sectional study of children aged 4 to 17 yearsRESULTS Enrolled 760 children 27 did not understand the Verbal NRS and were removed Reliability was strong in all age subgroups including each year of age from 4 -7 yearsCONCLUSION Convergent validity known-groups validity responsivity and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years Convergent validity was not strong for children aged 4 and 5 years Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older but not for those aged 4 and 5 years

46

Adult Verbal Alert and Oriented

Pain Management Putting it All Together

bull No Perfect Recipe or ldquoCookbookrdquo

bull No Universal Kid Recipe

Overview of PAMI Stepwise Approach to Pain (Adapted to Setting- ED Hospital EMS)

Ideal approach not always possible

Step 7 Monitoring amp Discharge Checkpoint

Step 6 Management Checkpoint

Step 2 Developmental or Cognitive Checkpoint

Step 3 Family Dynamic Checkpoint

Step 1 Situation Checkpoint

Step 5 Patient Assessment Checkpoint

Step 4 Facility Checkpoint

Step 1 Determine the Situation What are you trying to accomplish or manage

bull Pain only

bull Pain and anxiety or agitation

bull Anxiety only

bull Agitation only

bull Procedure that will induce pain or anxiety- transport IVhelliphelliphellip

bull Chronic pain condition exacerbation

Determination accomplished after brief triage history exam


Step 2 Perform a Developmental Checkpoint

bull What is the developmental stage of patient

bull Is development normal for agebull Developmental delaybull Autismbull Special health care needsbull Mental health concernsbull Recent traumatic events

bull Regression to lower developmental stage

What are characteristics of developmental stage in response to painHow do you adapt your approach based on developmental level

Kids and teens donrsquot always follow the charts

Step 2 Perform a Developmental or Cognitive Checkpoint

Responses to Pain by Age or Development

Age Group Understanding of Pain Behavioral Response Verbal Description

Preschoolers

3ndash6 years (preoperational)

Pain is a hurt Does not relate pain to illness may relate pain to an injury Often believes pain is punishment Unable to understand why a painful procedure will help them feel better or why an injection takes the pain away

Active physical resistance directed aggressive behavior strikes out physically and verbally when hurt low frustration level

Has language skills to express pain on a sensory level Can identify location and intensity of pain denies pain may believe his or her pain is obvious to others

School-Age Children

7ndash9 years (concreteoperations)

Doesnrsquot understand cause of pain Understands simple relationships between pain and disease and need for painful procedures to treat disease May associate pain with feeling bad or angry recognize psychologic pain related to grief and hurt feelings

Passive resistance clenches fists holds body rigidly still suffers emotional withdrawal engages in plea bargaining

Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts

10ndash12 years (transitional)

Better understanding of relationship between an event and pain More complex awareness of physical and psychologic pain(moral dilemmas mental pain)

May pretend comfort to project bravery may regress with stress and anxiety

Able to describe intensity and location with more characteristics able to describe psychologic pain

Adolescents

13ndash18 years(formaloperations)

Has a capacity for sophisticated and complex under-standing of causes of physical and mental pain Recognizes pain has qualitative and quantitative characteristics Can relate to pain experienced by others

Want to behave in socially acceptable manner -like adults controlled response May not complain if given cues from other healthcare providers

More sophisticated descriptions with experience may think nurses are in tune with their thoughts so donrsquot need to tell nurse about their pain


bull Who is with the child- parents siblingshellip

bull Who is the legal guardian

bull Who actually cares for the child

bull Who do you want to deal with

bull Culture past experience

bull What can they tolerate

bull Other priorities- another injured child etc

bull Family personality and stress level


Step 4 Facility (AgencyCommunity) Checkpoint

bull Staffing and setting

bull Community rural childrenrsquos hospital

bull Experience

bull Pediatric

bull Team capabilities and expertise

bull Existing hospitalagency policies

bull Acuity and overcrowding of the ED

bull Other priorities- MCI etc

bull Equipment monitoring backup



bull Review history assessment and risk factors

bull Chronic illness-previous painful experiences recent surgery

bull Psychiatric and mental considerations

bull Injury severity +- contraindications to opioids or sedation

bull Body habitus

bull Weight- ideal or real Obesity


Step 6 Management Checkpoint Choose Your ldquoReciperdquo

bull No magic recipe must individualize and adjust ldquoIngredientsrdquo

bull Pharmacologic ldquoingredientsrdquo

bull Route oral nasal IV nebulized topical nerve blocks

bull Type sucrose NSAID opioids anxiolytics ketamine

bull Nonpharmacologic ldquoingredientsrdquo

bull Everyone needs a little child life 101- distraction music swaddling

bull Engage caregivers and parents- coaching therapeutic language

Always consider nonpharmacologic options +- medications

Will pain duration be short (removal of FB laceration repair) or prolonged (burn)


Pain Management and Dosing Guide bull PAMI Stepwise Approach amp Guidebull Tutorial Videobull Adult and pediatric dosingbull Various administration routes

bull Topical amp transdermalbull Nasal nebulized oral IV IM

bull Nonpharmacologic interventionsbull Regionallocal nerve blocks and non-

opioid analgesic optionsbull Procedural sedation amp anxiolysisbull Discharge planning tipsbull QR codes and links to videos

Pediatric Pain Management- Pharmacologic

bull Oral- ibuprofen acetaminophen NorcoHycet(HydrocodoneAPAP)

bull Topical

bull IVINIM- ketorolac acetaminophen morphine fentanyl ketamine

bull Nerve blocks

Simple pharmacologic tips that patientsfamilies often forget or misunderstand

bull You can take acetaminophen and NSAIDs together

-check dosage and frequency of administration

-change NSAIDs

-beware of high risk populations

bull Topical medications for back pain

bull Car with 4 flat tires analogy ACPA

OTC Options are Overwhelming and Confusing

Patients receive very conflicting messages and want prescriptionsrdquo

Opioid Prescribing and Equianalgesic Chart Generic (Brand) Onset (O) and Duration (D) Approximate

Equianalgesic Dose

Recommended STARTING

dose for ADULTS


dose for CHILDREN (gt 6 mo)

Oral IV Oral IV Oral IV Oral IV

Morphine (MSIRreg) [CII] O 30-60 min

D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h

Morphine extended release (MS

Continreg) [CII]

O 30-90 min

D 8-12 h

mdash 30 mg 10 mg 15-30 mg q

12 h

mdash 03-06 mgkg q

12 h

mdash

Hydromorphone (Dilaudidreg) [CII] O 15-30 min

D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h

HydrocodoneAPAP 325 mg

(Norco 5 75 10reg) [CII]

Hycet (75 mg325 mg per 15 mL)

O 30-60 min

D 4-6 h mdash 30 mg mdash

5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]

(Sublimazereg Duragesicreg)

Patch for opioid tolerant patients

ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h

1-2 mcgkg q 1-2 h (max 50

mcgdose)

Non-Opioid Analgesics Generic (Brand) Adult Pediatric (lt12 yo)

Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h

Max 4 gd or 1 g q 4 h

15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)

Use only if not tolerating

PO

1 g IV q 6 h Max 4 gd or 650

mg q 4 h prn pain

lt50 kg 15 mgkg IV q 6 h or 125 mgkg IV q 4 h prn pain

Max 75mgkgd

Celecoxib (Celebrexreg) 100-200 mg

PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID

Ibuprofen (Motrinreg)

400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h

Max 40 mgkgd or 2400 mgd

Ketorolac (Toradolreg)15-30 mg IVIM q 6 h Max 120 mgd x 5 d

05-1 mgkg dose IMIV q 6 h Max 15-30 mg q 6 h x 5 d

Naproxen (Naprosynreg) 250-500 mg PO q 8 to 12 hMax 1500 mgd

5 mgkg PO q 12 hMax 1000 mgd

Intranasal and Nebulized MedicationsGeneric Dose Max Dose Comments

Fentanyl IN 15-2 mcgkg q 1-2 h

Neb 17-3 mcgkg

3 mcgkg or 100 mcg Divide dose equally

between each nostril

Midazolam

(5 mgmL)

IN 03 mgkg 10 mg or 1 mL per

nostril (total 2 mL)

Divide dose equally


Ketamine See Ketamine table

Lidocaine Neb 4 (40 mgmL)

100-200 mg or 25-5 mL

45 mgkg total or 300

mg

gt5 mgkg associated with

serious toxicity

Ketamine (Ketalarreg) Indications and DosingIndications Starting Dose

Procedural Sedation IV Adult 05-10 mgkg Ped 1-2mgkg

IM 4- 5 mgkg

Sub-dissociative Analgesia^ IV 01 to 03 mgkg

IM 05-10 mgkg IN 05-10 mgkg

Excited Delirium Syndrome IV 1 mgkg IM 4- 5 mgkg

Intranasal Medications

bull Use concentrated solution bull Ketamine 50 mgml

bull Fentanyl 50 mcgml

bull Midazolam 5mgml

bull Use an atomizerbull If gt 1ml divide between nares

bull Aim spray toward turbinatespinna

Rapid CSF levels

63

Ketamine Pharmacology

bull Blockade of N-methyl D-aspartate (NMDA) receptors peripheral Na+ channels and μ-opioid receptors providing sedation amnesia and analgesia

bull R(-) vs S(+) ketamine

bull S(+) enantiomer provides better analgesia (4x potent) but more auditoryvisual disturbances

bull High lipid solubility

bull allows rapid crossing of the blood-brain barrier

bull quick onset of action (peak concentration at 1 minute-IV)

bull Rapid recovery to baseline

64

61

Ketamine Timeline1960rsquos

bull Ketamine first synthesized --Calvin Stevens

bull Patented in US as an anesthetic amp sedative in humans

1970rsquos

bull FDA approved for human usemdashprimarily in pediatrics and elderly

bull Battlefield anesthetic during Vietnam War

bull Sedative agent for children

1980rsquos

bull Decline in use due to increased illicit use and emergence reactions

bull Ketamine first used to treat pain-1989

1990rsquos

bull Ketamine declared a Schedule III Drug controlled substance in the US

2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management

bull From the American Society of Regional Anesthesia and Pain Medicine the American Academy of Pain Medicine and the American Society of Anesthesiologists (Reg Anesth Pain Med 201843 456ndash466)

bull Evidence supports the use of subanesthetic ketamine for acute pain in a variety of contexts including as a stand-alone treatment as an adjunct to opioids and to a lesser extent as an intranasal formulation

Step 7 Monitoring And Discharge Checkpoint

bull Joint Commission standards

bull Document reassessments

bull Child should be back to baseline and tolerating fluids at discharge

bull Falls prevention

bull Transportation

bull Discharge planning and instructions

bull Pain plan


67

Require policies that address comprehensive clinical assessment of pain treatment or referral and reassessment

Hospitals required to hellipactively engage medical staff and leadership in improving pain assessment and management including strategies to decrease opioid use and risks provide ge one non-pharmacological modality facilitate access to PDMPs assess how pain affects physical function engage patients in pain treatment decisions and address patient education and engagement

Discharge Resources

bull httpskidshealthorgenparentsopioid-prescription-safetyhtml

bull httptheconversationcomseven-ways-to-soothe-your-childs-pain-in-the-hospital-83128

bull httpswwwtheacpaorg

bull Car with 4 flat tires

bull httpswwwyoutubecomwatchv=5RIii6OUK2A

69

Discharge Planning Toolkit for Pain

Algorithm bull Safe practicesbull Screening for opioid use disordersbull Identification of pain ldquorisk factorsrdquo

Patient discharge handouts and videos bull Sets realistic goalsbull Tips for managing pain at home

without opioidsbull Utilized by pain and other clinicsbull Incorporated into EMR DC

instructions

New Emphasis on Nonpharmacologic Methods of Treating Pain

Painting Analogy

Think of nonpharmacologic management as your ldquobase coatrdquo or ldquoprimerrdquo before applying additional coats of analgesic treatment With the right base coat foundation you have a better chance of painting a patientrsquos symptoms a more tolerable and long-lasting new color

(PEM Playbook httppemplaybookorgpodcastpediatric-pain


bull Nonpharmacologic pain management techniques should be considered along with pharmacologic techniques and may

bull improve assessment

bull decrease or avoid the use of opioids or anxiolytics

bull decrease time and recovery for procedures

bull decrease adverse events

Laceration example- distraction wound glue fan +-nasal midazolam

Using Nonpharmacologic Methods to Manage Pain and Anxiety

Development of a Distraction Toolbox

PAMI 3 Hour Pilot CoursendashNew Approaches to Pain Agenda

830-900 Registration

900-1000 Basics of ED and EMS Pain Management

bull Opening Pediatric and Adolescent Case Scenarios

bull Background of Pain Management in ED and EMS

bull PAMI Stepwise Approach to Pain Management

bull Responses to Pain by Developmental Stage

bull Overview of Pharmacologic Pain Management

bull Question amp Answer

1000-1100 Nonpharmacologic Pain Management

bull Conversation and Therapeutic Language

bull Coaching and Preparation

bull Psychological and Cognitive Behavioral

Interventions

bull PhysicalSensory Interventions

bull Distraction Toolbox Development

1100-1115 Break and Distribution of Distraction Toolboxes

1115-1215 Putting It All Together-Program Implementation Resources and Evaluation

bull Case Scenario Discussion

bull Educational Resources Supplies and Videos

bull Implementation in your Community

bull EMS Week

bull Community Resources and Networking Opportunities

bull Feedback and Questions

bull Name This Course

Nonpharmacologic Pain Management



bull Psychological and Cognitive Behavioral Interventions


Adapted from Krauss et al Current concepts in management of pain in children in the emergency department The Lancet 20151-10 httpdxdoiorg101016S0140-6736(14)61686-X and Cohen LL Behavioral approaches to anxiety and pain management for pediatric venous access Pediatrics 2008 122 (suppl 3) S134ndash39

Language to Avoid Language to Use

You will be fine there is nothing to worry about (reassurance) What did you do in school today (distraction)

This is going to hurtthis wonrsquot hurt (vague negative focus) It might feel like a pinch (sensory information)

The nurse is going to take some blood (vague information)First the nurse will clean your arm you will feel the cold alcohol pad

and nexthellip (sensory and procedural information)

You are acting like a baby (criticism) Letrsquos get your mind off of it tell me about that moviehellip(distraction)

It will feel like a bee sting (negative focus) Tell me how it feels (information)

The procedure will last as long ashellip (negative focus)The procedure will be shorter thanhellip (television program or other

familiar time for child) (procedural information positive focus)

The medicine will burn (negative focus)Some children say they feel a warm feeling (sensory information

positive focus)

Tell me when you are ready (too much control)When I count to three blow the feeling away from your body

(coaching to cope distraction limited control)

I am sorry (apologizing) You are being very brave (praise encouragement)

Donrsquot cry (negative focus) That was hard I am proud of you (praise)

It is over (negative focus)You did a great job doing the deep breathing holding stillhellip

(labelled praise)

Suggested language for caregivers parents and healthcare providers

Language to Avoid Language to UseThis is going to hurtthis wonrsquot hurt (vague negative focus)

It might feel like a pinch (sensory information)

I am sorry (apologizing)You are being very brave (praise encouragement)

Tell me when you are ready (too much control)

When I count to three blow the feeling away from your body (coaching to cope distraction limited control)

You are acting like a baby(criticism)

Letrsquos get your mind off of it tell me about that moviehellip(distraction)

Suggested Language

Categorization of NonpharmacologicInterventions

Physical (Sensory) Interventions

Positioning

Cutaneous stimulation

Nonnutritive sucking sucrose

Pressure

Hot or cold treatments

Others

Cognitive-Behavioral Interventions

Psychologic preparation education information

Distraction (passive or active) Video games TV movies phone lighted or interactive toy VR

Relaxation techniques (breathing meditation etc)

Music

Guided imagery

Training and coaching

Coping statements ldquoI can do thisrdquo

Adapted from Murray KK Hollman GA Non-pharmacologic interventions in children during medical and surgical procedures In Tobias JD Cravero JP eds Procedural Sedation for Infants children and adolescents Section on Anesthesiology and Pain Medicine American Academy of Pediatrics 2016

Cognitive Development

bull Because young children are cognitively immature physical comfort measures and distraction activities are more effective than verbal reasoning

bull Children do not have sufficient cognitive development to understand strangers trying to reassure them until age 5-7 years

Comfort Positioning

Comfort Positioning

bull Why use positioning for comfort

bull Sitting position promotes sense of

control and reduces anxiety

bull Puts child in a secure comforting hold

bull Promotes close contact with caregiver

bull Provides caregiver with an active role

May be prohibited in trauma patients

requiring immobilization and transport

74

Poster used with permission from Wolfson Childrenrsquos Hospital Child Life Department

Cold Therapy for Musculoskeletal Injuries

Rest

Ice

Compression

Elevate

Splinting

Dressing

PositioningIce or cold packs reduce swelling and pain in strains

sprains and fractures Do not put directly on bare skin

Cognitive-Behavioral Techniques

Types of Cognitive-Behavioral Interventions


Distraction (passive or active) Video games TV movies phone


Music

Guided imagery


Coping statements ldquoI can do thisrdquo or ldquothis will be over soonrdquo

DistractionDistraction is the most common type of cognitive-behavioral method

Used to guide attention away from painful stimuli It is most effective when adapted to the patientrsquos developmental and cognitive level

Research indicates that distraction can lead to reduction in procedure times and number of staff required especially in children Researchers hypothesize that children

ldquocannot attend to more than one significant stimulus at a timerdquo

Distraction is most effective when pain is mild to moderate (it is difficult to concentrate when pain is severe)

Why use distractionDoes not require advanced training for providers

Works with all developmental levels

Involves parents and caregivers during stressful times

Two Types of Distraction

Passive Distraction - attention redirected to a pleasurable stimulus or object

bull Storytelling

bull Showing a toy

Active Distraction - encourage participation in activities during procedure

bull Blowing bubbles

bull Playing a game

bull Interacting with electronic device

Can be used together or alone

Mechanisms of distraction in acute pain perception and modulation KA Birnie et al bull 158 (2017) 1012ndash1013 copy 2017 International Association for the Study of Pain (IASP) Permission for Use For clinical educational or research purposes reuse of this image is permitted for free with appropriate attribution to this article as the original source A high resolution copy of this image can be found online as Supplemental Digital Content at httplinkslwwcomPAINA418wwwpainjournalonlinecom

Distraction is more than ldquorainbows and butterfliesrdquo

Conversation and Distraction

To learn more visit

httpwwwjemscomarticlesprintvolume-38issue-7patient-care10-conversation-

starters-alternative-paihtml

Guided Imagery

bull Helps patients use imagination to divert thoughts from the pain or procedure to a more pleasant experience

bull Helps patients use their imagination to create a descriptive story

bull Guided Imagery Options

76

Option 1- Visit a ldquorelaxingrdquo place and change image of pain or turn off

pain with a ldquopain switchrdquo in the brain Ask patient to locate the pain

switch and turn down level of pain to a more comfortable level

Option 2- Identify a ldquopainrdquo color and a ldquocomfortrdquo color Ask patient to

breathe in the ldquocomfortrdquo color and breathe out ldquopainrdquo color OR ask

patient to associate their pain with a color then view the painful part of

their body in that color Imagine shrinking fading or dispersing thepainful color or even sending it away in a balloon

Option 3- Symbolic imagery can be used in adults and adolescents If a

patient with severe arthritis pain complains of pain in one joint ask them

to think about how the pain feels Does it feel like a knife Imagine

pulling the knife out and throwing it away Focusing on an affirmation can

also help ldquoI am removing the knife and throwing it awayrdquo

Music Therapy

bull Additionally benefits parents and health care providers caring for the anxious patient

bull Many larger hospitals have music therapists or volunteers

Beneficial in reducing pain anxiety and stress in EDs waiting rooms procedure rooms and during transport

bull Ways to implement

bull Have patient select music from available electronic devices or their own- keep supply of disposable headphones or earbuds

Designing Your Distraction Toolkit

bull Components

bull Safety

bull Setting

Distraction amp Nonpharmacologic Toolkit

bull Reduces anxiety amp pain

bull Avoids or decreases dosages of pharmacologic treatments such as opioids and benzodiazepines

bull ED EMS Trauma Center Radiology suites PICU others

bull Three hour pilot course apps and toolbox components available online

Distraction Toolbox Components

Rubikrsquos cube

Glitter iSpy wand

Hotcold packs DistrACTION Cards

LED keychains

Pacifier amp Sucrose Water

ldquoOink Oinkrdquo


Liquid-in-motion

Lighted amp motion toy

Stress Balls

Mad Libs

Wikki Stix

Buzzy ndash cold numbing vibrating

Stickers

Patient Safety Considerations

bull Infection Controlbull Individual use- child keeps or disposes of the item

(teddy bear pacifiers teethers Wikki Stix ice packs)

bull Multiple use items ensure item can be sanitized (local policies)

Sani-Cloth CHG 2 (chlorhexidine 2alcohol 70)

bull Choking Hazardsbull Make sure item is age appropriate

bull No small pieces or easily breakable toys (lt3 years or older if developmentally delayed)

bull Ensure items with gel or liquid ingredients are nontoxic

Beware of siblings or other children in the room

Nonpharmacologic Measures Preschoolers

bull Provide calmest environment possible

bull Cold or hot packs

bull Allow position of comfort if safe

bull Light touch or massage

bull Music or video on phone or iPad

bull Stress ball pinwheels bubbles

bull Toys with lights and sounds

bull Distraction cards find objects

bull Look at or read storybooks

bull Singing or storytelling

bull Distracting conversation

bull Coach child through the process

Resources Literature Videos Websites Apps Vendors and More

bull Many excellent resources available bull PAMI website includes a list of resources

and references bull Let us know if you have suggestions or see

something new

The Power of Videos and Cute Kids

Managing Procedural Anxiety in Children

httpwwwnejmorgdoifull101056NEJMvcm1411127

It Doesnrsquot Have to Hurt Distraction httpswwwyoutubecomwatchv=KgBwVSYqfps

Baby Getting Shotshttpswwwyoutubecomwatchv=MOOxpT9q2mo

BreathingRelaxa-tionImagery

Age Development

Tips for Use Cost

YouTube All Search for ldquoGuided Imagery for kidsrdquo ldquoPainrdquo or ldquoAnxietyrdquo or ldquoSuperherordquo

Free

Settle Your Glitter 4-15 years old Children shake the device and mimic blowfishrsquos breaths to help work out stress or anger

Free

Stop Breathe Think 10-18 years old Guided meditation and breathing exercises assist tweens and teens and allow them to ldquosharerdquo how they feel

Free

Healing Buddies Comfort Kit

4-18 years old Select a feeling and then learn positive coping mechanisms Includes ldquoPainrdquo and ldquoWorriedrdquo which makes an excellent app to use with all ages

Free

Virtual Reality

Virtual Reality

bull Engages the patient in a 360 degree visual and auditory experience which removes primary focus from the pain or anxiety

bull Headsets range from high tech expensive options such as appliedVR to inexpensive cardboard viewers

bull Type of viewer could depend on area used in ie a inpatient floor or outpatient clinic is more controlled than an ED or Trauma setting

bull Wound care infusions procedures labor and delivery

Virtual Reality for Pain Management amp Distraction

Parting Thoughts- Beware ofhelliphelliphellip

bull Drug seeking parents

bull Pregnant and postpartum patients in pain andor at risk for addiction

bull Extrapolation of adult pain management procedures to children

bull Analgesic medication errors due to drug shortages

bull Falls and driving after sedation procedures or pain medications

bull Cycle of decreased movement after injuryrarrdepression rarrdecreased sleeprarr decreased mobility chronic painhelliphelliphelliphellip

bull Profiling and stereotyping (GSW and SSD examples)

Futurehelliphelliphellip

bull Ketamine old drugs used in new ways (lidocaine) US guided nerve blocks nonpharmacologic interventions mindfulness sleep therapies etc

bull Legislation and EducationCFMSDs Pain Management and Opioid Stewardship Education for Florida Medical Schools Framework for Developing Core Competencies amp Guide for Curriculum

PAMI 30 Multimodal Approaches to Improve Patient Outcomes and Reduce Opioid Risk

CHFM Survey ResultsDo we want a pediatric survey

Questions and Comments

References and resources can be found on the main PAMI website


Email your comments ideas change of practice recommendations challenging cases and questionsemresearchjaxufledu

phyllishendryjaxufledu

(904) 244-4072 or 244-8617


Pediatric Pain Management in an Anti-Opioid Environment

Challenges and Resources

FINANCIAL DISCLOSUREI have no relationship with a

commercial supporter

UNLABELEDUNAPPROVED USES DISCLOSURE None

Learning Objectives








bull Pediatric

bull EM

bull Trauma

bull EMS
















PAMI mission




2014-present





















Assessment



















bull Pain MCI




Support





Acute Care


Health Settings














reduction




puncture

Chesttube insertion


patients


Laceration repair







or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

Learning Objectives








bull Pediatric

bull EM

bull Trauma

bull EMS
















PAMI mission




2014-present





















Assessment



















bull Pain MCI




Support





Acute Care


Health Settings














reduction




puncture

Chesttube insertion


patients


Laceration repair







or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617



bull Pediatric

bull EM

bull Trauma

bull EMS
















PAMI mission




2014-present





















Assessment



















bull Pain MCI




Support





Acute Care


Health Settings














reduction




puncture

Chesttube insertion


patients


Laceration repair







or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617













PAMI mission




2014-present





















Assessment



















bull Pain MCI




Support





Acute Care


Health Settings














reduction




puncture

Chesttube insertion


patients


Laceration repair







or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617





















Assessment



















bull Pain MCI




Support





Acute Care


Health Settings














reduction




puncture

Chesttube insertion


patients


Laceration repair







or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617















bull Pain MCI




Support





Acute Care


Health Settings














reduction




puncture

Chesttube insertion


patients


Laceration repair







or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617




Support





Acute Care


Health Settings














reduction




puncture

Chesttube insertion


patients


Laceration repair







or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617










reduction




puncture

Chesttube insertion


patients


Laceration repair







or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617






or staff




Post-operative pain


20

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

Recurrent pain

Under-treated

pain


Pain memory


Coping

Developmental age

Past experience

Temperament


21








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617








experiences as an



management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


management is scant


































28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617



















28










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617










31





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617





bull Genetics



32



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617



Perform behavioral

observation

Question the child


tool

33

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

Consider




Explore









Perform behavioral

observation

Question the child

Use standardized

assessment tool

34





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617





problem






35

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

36











37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


37








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617








38


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


bull Age


bull Condition




39


Perform behavioral

observation

Question the child

Use standardized

assessment tool





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617





40















(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617













(ages 1-7)




42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


42


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


43


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


44

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

45




46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

46















bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617














bull Pain only


bull Anxiety only

bull Agitation only














Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617










Preschoolers





School-Age Children









Adolescents


















bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617














bull Experience

bull Pediatric












bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617






bull Body habitus




















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


















bull Topical


bull Nerve blocks




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617




-change NSAIDs







Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617




Equianalgesic Dose


dose for ADULTS





D 3-6 h

O 5-10 min

D 3-6 h

30 mg 10 mg 15-30 mg q

2-4 h

2-10 mg q

2-4 h

03 mgkg q 4

h

01 mgkg

q 2-4 h


Continreg) [CII]

O 30-90 min

D 8-12 h


12 h

mdash 03-06 mgkg q

12 h

mdash


D 4-6 h

O 15 min D

4-6 h

75 mg 15 mg 2-4 mg q 4

h

05-2 mg q

2-4 h

006 mgkg q 4

h

0015 mgkg

q 4 h




O 30-60 min


5-10 mg q

6 h mdash

01-02 mgkg q

4-6 h mdash

Fentanyl [CII]



ONLY

Transdermal

O 12-24 h

D 72 h per

patch

O immediate

D 30-60 minmdash

100 mcg

(01 mg)

Transdermal

12-25 mcgh

q 72 h

50 mcg q

1-2 h

Transdermal

12-25 mcgh q

72 h


mcgdose)


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


Acetaminophen

(Tylenolreg)

325-650 mg

PO q 4-6 h


15 mgkg

PO q 4-6 h

Max 90 mgkgd

Acetaminophen

IV (Ofirmevreg)


PO


mg q 4 h prn pain


Max 75mgkgd


PO daily to q 12 h

Max 400 mgd

gt2 yo

50 mg PO BID


400-800 mg PO q 6 to 8 hMax 3200 mgd

10 mgkg

PO q 6 to 8 h








Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617



Neb 17-3 mcgkg



Midazolam

(5 mgmL)



Divide dose equally




100-200 mg or 25-5 mL


mg


serious toxicity



IM 4- 5 mgkg










Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617







Rapid CSF levels

63









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617









64

61




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617




1970rsquos




1980rsquos



1990rsquos


2000rsquos

bull Increased

use in

treatment of

acute amp

chronic pain

bull Ketamine as

treatment for

depression









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617









bull Transportation


bull Pain plan


67



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617



Discharge Resources






69





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617





instructions


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


Painting Analogy

























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617























Interventions








bull EMS Week




















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

















positive focus)






(labelled praise)









Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617








Suggested Language



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617



Positioning



Pressure


Others





Music

Guided imagery







Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617




Comfort Positioning

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

Comfort Positioning









74



Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


Rest

Ice

Compression

Elevate

Splinting

Dressing








Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617






Music

Guided imagery













bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617











bull Storytelling

bull Showing a toy



bull Playing a game






To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617




To learn more visit



Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

Guided Imagery




76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

76













Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

Music Therapy







bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


bull Components

bull Safety

bull Setting







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617







Rubikrsquos cube

Glitter iSpy wand


LED keychains


ldquoOink Oinkrdquo


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


Liquid-in-motion


Stress Balls

Mad Libs

Wikki Stix


Stickers


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617


























something new







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617







Age Development

Tips for Use Cost


Free


Free


Free



Free

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

Virtual Reality

Virtual Reality
























(904) 244-4072 or 244-8617

Virtual Reality
























(904) 244-4072 or 244-8617




















(904) 244-4072 or 244-8617

Pediatric Pain Management in an Anti-Opioid Environment: Challenges and Resources · 2018-09-18 ·...

Documents

Transcript of Pediatric Pain Management in an Anti-Opioid Environment: Challenges and Resources · 2018-09-18 ·...