The Effect of Pain Medication in Children With Acute Abdominal Pain and Its Implication Over the Surgeon's Decision
The Effect of Pain Medication in Children With Acute Abdominal Pain and Its Implication Over the Surgeon's Decision
Surgeons are the individuals who will operate on a patient if it is determined to be
 necessary after they present with abdominal pain. For that reason, the investigators want to
 study if giving a medicine (morphine) to children presenting to the ED with abdominal pain
 will alleviate pain without changing the patient's physical exam and the subsequent surgeon's
 decision.

 The investigators also will record any side effects of morphine, any associated surgical
 complications, and to identify the ultimate diagnosis.
Unfortunately, the current standard of care obviates the use of pain medication in children
 with acute abdominal pain while waiting for the attending pediatric surgeon to perform their
 examination and determine if the patient requires operative intervention. This process can
 sometimes be protracted.

 This practice occurs currently because of the concerns that analgesia may alter physical
 findings, interfere with the diagnosis, and delay definitive surgical intervention resulting
 in increased morbidity. This point of view has been challenged recently.

 We designed this study taking into account the paramount importance of the pediatric
 surgeon's role in determining the need for operative intervention in the ultimate management
 of patient's presenting with acute abdominal pain and signs and symptoms of peritonitis.

 Our primary objective is to demonstrate that the administration of intravenous morphine will
 alleviate pain in children presenting to the Emergency Department (ED) with abdominal pain
 and peritoneal signs, without changing the patient's physical exam and the subsequent
 surgeon's operative decision.

 Secondary objectives include recording any adverse events of morphine and associated surgical
 complications, and identification of the ultimate diagnosis.

 This is a prospective, randomized double-blind, placebo-controlled clinical that will be
 conducted in the ED at Children's Medical Center of Dallas. Children aged 1 to 18 years with
 acute abdominal pain of ≤ 3 days duration, a moderate to severe pain score, and the presence
 of peritoneal signs will be eligible. Patients will be randomized to receive either 0.1mg/kg
 of intravenous morphine (maximum 10 mg) or an equal volume of placebo (0.9% saline).

 An ED physician will obtain clinical data, determine the pain score, write a presumptive
 diagnosis and place an order for the study medication. A surgical physician will also obtain
 clinical data and write his/her disposition. This evaluation will be repeated at 30-120
 minutes after administration of the study medication by the ED and surgical physicians.

 Each subject will be monitored for 2 weeks after enrollment for follow-up.
Inclusion Criteria:

 -  Children aged 1 to18 years of age who present with acute abdominal pain and signs of
 peritoneal irritation of less than 5 days duration.

 -  Pain scores from moderate to severe

 -  Need for intravenous access and require surgical consultation.

 Exclusion Criteria:

 -  Pregnancy

 -  Chronic pain (defined as pain of more than two weeks' duration). 3. Constipation
 (Bowel movement less than 3imes/week, hard, small, or difficult to eliminate)

 -  Prior abdominal surgery or traumatic abdominal pain.

 -  History of gastritis, peptic ulcer disease, gastro esophageal reflux disease.

 -  Chronic illnesses associated with pain such as Ulcerative colitis, Crohn's disease,
 sickle cell disease or altered perception to pain (autism, spina bifida, altered
 mental status).

 -  Previous use of morphine sulfate or other narcotic/medication known to alter pain

 -  Perception or mental status six hours prior to presentation in the ED.

 -  Prior allergy or anaphylaxis to morphine.

 -  Acute respiratory distress, hypotension (less than 5thpercentile for age).

 -  Renal, pancreatic or biliary disease