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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Pediatric ED Treatment Guidelines : Pain Management & Suspected Appendicitis

Introduction

The most common serious, pediatric, abdominal emergency is appendicitis.(1) Nearly all children with appendicitis present with abdominal pain. A long held assumption has been that treatment of pain in children with suspected appendicitis will mask the signs and symptoms associated with appendicitis and delay diagnosis and surgical treatment. Two recently published double-blind, randomized, placebo-controlled studies in children > 5 years of age with suspected appendicitis found no significant change in diagnostic accuracy between the morphine vs placebo treated groups.(2, 3) In both studies morphine compared to placebo significantly reduced pain at dose of 0.1 mg/kg (single dose) and 0.05 mg/kg (maximum of 2 doses). Therefore, the following Pediatric Emergency Department treatment guideline for pain management is recommended for children with suspected appendicitis who experience substantial pain while awaiting surgical intervention.

Patient Population

Consider pain management with morphine for the following children:

  • 5 to 17 years of age
  • non-traumatic abdominal pain
  • pain < 48 hours
  • right lower quadrant abdominal tenderness
  • significant pain ( > 5 on a scale of 1 to 10)
  • surgical consultation
  • no allergy to narcotics

Dosage

0.05 mg/kg intravenous, maximum single dose 5 mg, every 30 minutes for 2 doses

Monitor

Monitor for apnea, hypoxia, hypotension, change in level of conscious and allergic reaction. For life threatening adverse reactions consider naloxone 0.1 mg/kg, maximum single dose 2 mg intravenous.

References

  1. Reynolds SL, Jaffe DM. Children with abdominal pain: evaluation in the pediatric emergency department. Ped Emerg Care. 1990;6:8-12.
  2. Green R, Bulloch B, Kabani A, et al. Early Analgesia for Children with Acute Abdominal Pain. Pediatrics. 2005;116:978-983.
  3. Kim MK, Strait RT, Sato TT, et al. A Ramdomized Clinical Trial of Analgesia in Children with Acute Abdominal Pain. Acad Emerg Med. 2002;9:281-287.


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