You are consulted for pain management for a 4 year-old, 20 kg child with profuse watery stools due to suspected viral illness. He is tachycardic and irritable in his mother’s arms. The most appropriate plan of care is:
a) Administer meperidine
b) Administer IV morphine continuous PCA
c) Administer IM ketorolac
d) Administer enteral oxycodone
e) Administer IV isotonic fluids
Answer e. The patient described is the scenario is tachycardic and irritable and has a history of profuse diarrhea. Based on this information alone, there is concern for hypovolemic shock; it is important to attempt to differentiate pain from other causes of physiologic abnormalities. Adequacy of airway, breathing, and circulation should be assessed prior to administering any potentially vasodilating analgesic medications. After fluid resuscitation, many patients will have resolution of tachycardia (a sign of shock) and irritability (which may be due to brain hypoperfusion), and may not need additional analgesics. If further therapy is needed, non-pharmacologic strategies should be employed first. Meperidine is no longer recommended for use in children; nor are IM injections. Enteral medications work very well but should be used with caution in patients with acute gastroenteritis. Continuous opioids are relatively contraindicated for patients with gastroenteritis due to the theoretical risk of bowel perforation.