Tasty Morsels of EM 078 – #FRCEM Paeds Analgesia

26 Jul

(Featured image: via Ben Avey on wikimedia commons, public domain)

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

Describe intranasal diamorphine?

(from the OHEM)

  • unlicensed use I think but common practice
  • Contraindications:
    • Age<1,
    • Weight<10kg
    • nasal obstruction
    • base of skull fracture
  • Dosing
    • 0.1mg/kg in a volume of 0.2ml
    • add appropriate amount saline to get the right concentration – in reality use a pre made table as this is way too easy to screw up
    • If using a MAD device remember there is 0.1 ml dead space so you need to draw up 0.3ml of your solution

How do you use intranasal fentanyl?

Fentanyl (From Melbourne RCH guidelines)

  • Increasingly common
  • Dose
    • 1.5 mcg/kg (can be repeated)
    • use the 100mcg/ml concentration (what we usually use for IV use)
    • MAD recommended and remember the 0.1ml dead space
    • Split between the nostrils

What are the RCEM standards for paeds analgesia?

2017 guidance

  • moderate or severe pain – analgesia within 20 minutes and reevaluated 60 mins later

What are some of the main recommendations from RCEM Ketamine guidance?

2016 Update

  • fasting considered but not absolute contraindication
  • 3 staff minimum
  • 1mg/kg IV, 2.5mg/kg IM (with supplementals of 0.5mg/kg IV and 1mg/kg IM)
  • Contraindications include
    • <12 (12-24 with expert)
    • risk of spasm
    • airway issues
    • psych issues
    • porphyria
    • procedure in the mouth or pharynx
    • intracranial hypertension with CSF obstruction (this is probably one of the most genuine contraindications)
  • recovery in 60-120 mins
  • should mobilise and communicate to pre sedation levels before home. leave food for 1-2 hours
  • no routine atropine or midazolam



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