Hannah Skuse and Vanessa Lawlor consider methods and outcomes of analgesia among children experiencing pain after severe injuries intranasal DiaMorpHine in cHilDren WitH trauMa

Best practice in treating children in severe acute pain, according to the college of emergency Medicine children’s pain assessment tool (2010), is to administer intravenous (iV) morphine or intranasal diamorphine. this article discusses the intranasal delivery of analgesia, which according to Kidd et al (2009) is less traumatic than the potentially difficult and distressing iV route. a survey of the use of intranasal medication for children in all emergency departments (eDs) in england and Wales (Hadley et al 2010) found that staff in most of them administer intranasal medications, usually diamorphine. the researchers conclude that administration of intranasal diamorphine is a safe and effective way to manage moderate-to-severe pain in children, and they hope that it will become more widespread. Much of the evidence that supports the administration of intranasal diamorphine derives from Kendall et al’s (2001) randomised controlled multicentre trial of intranasal diamorphine as an analgesia for children and teenagers with clinical fractures. results of the trial, in which the effectiveness of intranasal diamorphine was compared with that of intramuscular (iM) morphine, show that pain scores from children in the intranasal diamorphine and iM morphine groups improved over time, but that the onset of analgesia was faster in the intranasal diamorphine group. the adequacy of analgesia, which was assessed by calculating times until rescue analgesia was needed, was the same in both groups (Kendall et al 2001). as part of the trial, nurses were asked to record children’s reactions to each of the administration methods under one of four categories: ‘no obvious discomfort’, ‘mild reaction’, ‘winced or withdrew’, ‘cried or screamed’. the researchers conclude from this aspect of their trial that children or young people given iM analgesia become more distressed than those given intranasal analgesia. to assess the acceptability of intranasal analgesia, the researchers asked nurses and parents to describe each of the two forms of administration in one of four ways: ‘acceptable’, ‘stressful’, ‘very stressful’ or ‘unacceptable. results show that nurses and parents think that intranasal analgesia is more acceptable than iM analgesia. Most importantly, the safety profile of intranasal diamorphine has been established as acceptable, with no serious adverse events noted (Kendall et al 2001). the study concludes that intranasal diamorphine is a safe and effective Opposite: helping children to indicate the level of pain they are experiencing on illustrated pain scales enables staff to ascertain how much analgesia they need Correspondence [email protected]