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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD



Pain Control Recommendations

Tenet #1  -  If the patient says he/she has pain - he/she has pain.

Tenet #2  -  Analgesics are most effective when given on a regular basis (not as  needed or required).

Tenet #3  -  Intra-muscular injections are not usually appropriate because the child fears the injection as much as the pain (when IM injections are given, EMLA cream  should be used).

Tenet #4  -  Bowel management begins with the narcotic pain management.

Tenet #5  -  Pain management protocol should be initiated beginning with the following suggested doses.  These are starting doses to be modified as the situation dictates in consultation with faculty.

Exceptions:  This protocol includes the following exceptions in which each dose of pain medication should be individualized for each situation.  The following patients will be handled by the senior resident in consultation with faculty  -- 

  First 24-48 hours post-burn wherein blood flow is reduced to all organs if patient is in shock.
  Respiratory difficulty - any cause, if not intubated.
  Septic shock patient.
  Malnutrition, unless approved by faculty.

Background Pain:

  1)  Begin with Acetaminophen:

Acetaminophen dose = 15 mg/kg/dose PO q4h
Draw acetaminophen blood levels starting one day after scheduled acetaminophen is begun.  Draw level one hour after dose is given, then weekly thereafter on Mondays.
Therapeutic Level = 10-30 ug/ml
Toxic Level = >50 ug/ml

  2)  If the pain is not controlled, give morphine in addition to acetaminophen:

IV Morphine dose = 0.03 mg/kg/dose IV q4h
PO Morphine dose = 0.1 to 0.3 mg/kg/dose PO q4h

  3)  If morphine is given in children less than 3 years of age, these rules must be followed:

a.  Do not give if asleep.
b.  Do not give for sleep - give only for pain.
c.  Do not give during initial resuscitation (i.e., first 24 hours post-injury).
d.  Do not give if patient is in shock or is septic.
e.  Give only if the patient is being monitored for ECG, respiration, pulse and oxygen saturation.
f.  Do not give if the respiratory rate is less than 20 or the oxygen saturation is less  than 95%.
g.  If the patient is still in pain, call faculty.  Do not increase the morphine dose without faculty approval.

  4)  Levorphanol (Levo-Dromoran):

Use only in patients that are over 16 years of age and > 50 kg in weight.  Call psychiatrist-on-call prior to ordering this medication.
Levorphanol dose = 2 mg PO q6-24h prn pain.

  5)  Taper narcotics over 3 days.

  6)  Ibuprofen (when anti-inflammatory action is also indicated)

Ibuprofen dose = 10 mg/kg PO q4h.
Do not prescribe for others without approval from the psychiatrist-on-call.

Bowel Regimen:

1)  Start with the following anytime narcotics are administered -

Prune Juice

< 5 years

2 oz.

> 5 years

4 oz.
  > 10 years 6 oz.


Docusate Sodium < 3 years 25 mg/day
(Colace) 3-6 years 50 mg/day
  6-12 years 100 mg/day

2)  Then, add one of the following if the patient becomes constipated:

a.  Mineral Oil   --   1-3 oz./day
b.  Mini-enema (Colace - glycerine) if no bowel movement by noon
c.  SBH enema if no bowel movement by 15:00 hours

Benzodiazepines for Baseline Anxiety:

1)  Before using anxiolytics:
  Address pain management
  Address Acute Stress Disorder (ASD) problems

2)  Lorazepam
  IV or PO Lorazepam dose:  0.03 mg/kg/dose q4h
  Lorazepam taper for patients on Lorazepam for > 15 days:
Reduce dose by 50% every 2nd day and then reduce frequency.
May be tapered post-discharge, if necessary.

3)  Diazepam
  Useful for rehabilitation therapy because it relaxes skeletal muscle.
  Longer half-life than Lorazepam or Midazolam.  No taper necessary.
  IV or PO Diazepam dose:  0.1 mg/kg/dose q8-12h

Procedural Pain Relief and Anxiety Management:

1)  For all age groups.

2)  To be added in addition to background pain management.

3)  The Child Life Therapy Department may be consulted before the procedure for teaching and development of coping skills.

4)  Procedural pain medication should be scheduled 30 minutes to 1 hour pre-procedure rather than prn.

5)  An anxiolytic with amnesic properties should be given in conjunction with the pain medication (Lorazepam or Midazolam are more potent amnesics than diazepam).

6)  Procedural Pain Medication for Dressing Changes:  Increase these doses if pain is not well-controlled and over-sedation is not seen.
a.  Acetaminophen 15 mg/kg/dose may be used if patient does not require     opiate therapy.
b.  Morphine dose for procedural pain is typically twice the dose for background pain --
    PO Morphine dose:  0.3 - 0.6 mg/kg/dose (if >15kg)
    IV Morphine dose:  0.05 - 0.1 mg/kg/dose (if >15kg)
c.  Fentanyl Oralet dose:  10 mcg/kg/dose rounded to nearest hundred.
    (Fentanyl Oralets available in 100mcg, 200mcg, 300mcg and 400mcg.)

7)  Procedural Anxiolytics for Dressing Changes:
a.  IV or PO Lorazepam dose:  0.05 mg/kg/dose.

8)  Pain Medication for Pre-Rehab Therapy:  On request of the therapist 30 minutes before exercise --
a.  Morphine
     PO Morphine dose:  0.1 - 0.3 mg/kg/dose
     IV Morphine dose:  0.03 mg/kg/dose
b.  Hydrocodone/Acetaminophen Combinations
     Hydrocodone dose:  0.2 mg/kg/dose
Lortab Elixir:  Each 5ml contains 2.5mg Hydrocodone and 167mg
          Lortab Elixir dose:  0.4 ml/kg/dose
     → Vicodin Tablet:  Each tablet contains 5mg Hydrocodone and 500mg
          Vicodin dose:  1 tablet/25 kg

9)  Pain Management for Acute Patients During Post-Operative Period:
a.  Patient Controlled Analgesia (PCA):  Recommended for children >5 years old undergoing reconstructive surgery and considered for acute patients.  Quality of analgesia should be assessed frequently by the nursing staff.  Inadequate pain control should be reported to the primary physician as soon as discovered.  PCA is discontinued when pain can be controlled adequately by oral medication.
     → Morphine PCA -
          PCA dose:  0.01 - 0.015 mg/kg
          Lockout:  6 - 10 minutes
          4 hour limit:  0.24 - 0.3 mg/kg
     → Meperidine PCA -
          PCA dose:  0.15 - 0.2 mg/kg
          Lockout:  6 - 10 minutes
          4 hour limit:  2.5 mg/kg
b.  Morphine Continuous Infusion via PCA pump:
          Infusion dose:  0.015 mg/kg/hour  and/or
          Self/administered bolus:  0.05 mg/kg
c.  Nurse or Physician administered bolus:
          Morphine IV  0.02 - 0.03 mg/kg/dose q2h
          (hold if level of responsiveness < 3)

10)  Pain Management for Reconstruction Patients During Post-Operative Period:
a.  Hydrocodone/Acetaminophen Combinations:  Do not give concomitantly with Tylenol --
     → Hydrocodone dose:  0.2 mg/kg/dose PO q4h prn pain
     → Lortab Elixir:  Each 5ml contains 2.5mg Hydrocodone and 167mg
          Lortab Elixir dose:  0.4 ml/kg/dose
     → Vicodin Tablet:  Each tablet contains 5mg Hydrocodone and 500mg
          Vicodin dose:  1 tablet/25 kg
b.  Morphine:  If pain is not controlled with hydrocodone/acetaminophen combination or patient is not on morphine PCA --
           IV Morphine dose:  0.05 mg/kg/dose IV q4h prn pain
           PO Morphine dose:  0.3 mg/kg/dose PO q4h prn pain

11)  Opiate and Benzodiazepine Reversal Agents:  Flumazenil and Naloxone (NarcanTM) at bedside - Physician is called whenever flumazenil or naloxone are administered.
    Doses as follows --
     → Flumazenil for Reversal of Benzodiazepines:
           < 40 kg:  0.01 mg/kg (max. 0.2 mg)
                          then after 45 seconds, 0.005 - 0.01 mg/kg (max. 0.2 mg)
                          then every 60 seconds to 1 mg max. dose.
           > 40 kg:  0.2 mg over 15 seconds.
May repeat 0.2 mg dose over 45 seconds,
                           then every 60 seconds to 1 mg max. dose.
     → Naloxone (NarcanTM) for Reversal of Opiates:
          (Dilute 0.4 mg/ml ampule in 10 ml of NS = 0.04 mg/ml)
           < 20 kg:  Give 1 ml = 0.04 mg.  May repeat every 1 minute x 3 doses
           > 20 kg:  Give 2 ml = 0.08 mg.  May repeat every 1 minute x 3 doses


  Ketamine:  Titrate to effect according to pain stimulus and respiratory function.  Repeated doses of ketamine may increase tolerance to effect.

a.  Children
        IV Ketamine dose:  1 -2 mg/kg/dose.
        May repeat dose every 20 minutes if child vocalizes pain.
        IM Ketamine dose:  3 - 7 mg/kg/dose.
        Give only when there is no peripheral IV access.
        PO Ketamine dose:  6 - 10 mg/kg/dose.

b.  Adults
        For patients that are > 16 years of age and > 50 kg in weight, order benzodiazepines in conjunction with ketamine to counteract higher incidence of hallucinations and nightmares in adults receiving ketamine.
        IV Ketamine dose:  1 - 2 mg/kg/dose, titrate to effect
        IM Ketamine dose:  3 - 8 mg/kg



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