Contraindications to ibuprofen?
- Obvious significant pain (source not important)
- Hx of high risk airway disease, surgery or tracheostomy
- Respiratory distress or oxygen requirement
- Head/mid-face trauma, LOC or mental status changes
- Toxic appearance
Contraindications to PO?
Contraindications to acetaminophen?
Consultations with physician qualified to manage acute pain
IV access already established?
Contraindications to intranasal fentanyl?
Contraindications to IV morphine?
Still severe pain after 5 min?
Qualitative assessment of pain - Wong-Baker FACES or r-FLACC (by any provider - MD, RN, etc.)
>30 kg?
Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) Tool
Variable | 0 points | 1 point | 2 points |
Face | No particular expression or smile | Occasional grimace/frown; withdrawn or disinterested; appears sad or worried | Consistent grimace or frown; frequent/constant quivering chin, clenched jaw; distressed-looking face; expression of fright or panic |
Legs | Normal position or relaxed; usual tone & motion to limbs | Uneasy, restless, tense; occasional tremors | Kicking, or legs drawn up; marked increase in spasticity, constant tremors or jerking |
Activity | Lying quietly, normal position, moves easily; regular, rhythmic respirations | Squirming, shifting back and forth, tense or guarded movements; mildly agitated (e.g. head back and forth, aggression); shallow, splinting respirations, intermittent sighs. | Arched, rigid or jerking; severe agitation; head banging; shivering (not rigors); breath holding, gasping or sharp intake of breaths, severe splinting |
Cry | No cry/verbalization | Moans or whimpers; occasional complaint; occasional verbal outburst or grunt | Crying steadily, screams or sobs, frequent complaints; repeated outbursts, constant grunting |
Consolability | Content and relaxed | Reassured by occasional touching, hugging or being talked to. Distractible. | Difficult to console or comfort; pushing away caregiver, resisting care or comfort measures |
Non-pharmacological actions for pain control
- Child life involvement
- Parental involvement
- Distraction techniques
- Relaxing / Safe environment
Reassessment of pain level every 30 min
Examples of high risk airway diseases
- Active obstructive sleep apnea
- Active pneumonia or airway infection
- Severe asthma
- Chronic lung disease
- Neuromuscular disorders impacting breathing (MD, SMA, etc)
- Note: many more exist
Consultation with physician qualified to manage acute pain.
Reassessment of pain level every 30 min
