Adequacy of Pain Management in Children with Long Bone Fractures

Posted by Patrick Lickiss on Feb 15, 2012 in General, Research, Treatment | 8 comments

Continuing last week’s theme of trauma related research, today’s study is from the journal Pediatric Emergency Care and looks at emergency room management of pain in pediatric patients suffering from isolated long bone fractures. The researchers underwent a retrospective study to determine if patients ages 0-15 years were given adequate dosing based on standard, inadequate dosing or no pain medication at all when they presented with single long-bone fracture.

Here’s the abstract:

Pediatr Emerg Care. 2012 Jan 20. [Epub ahead of print]

Analgesic Administration in the Emergency Department for Children Requiring Hospitalization for Long-Bone Fracture.

Dong L, Donaldson A, Metzger R, Keenan H.

From the *Intensive Medicine Clincal Program, Intermountain Healthcare; †Department of Pediatrics, University of Utah; ‡Division of Pediatric Surgery, University of Utah School of Medicine, Primary Children’s Medical Center; and §Department of Pediatrics, University of Utah, Salt Lake City, UT.

OBJECTIVES: The objective of the study was to describe analgesia utilization before and during the emergency department (ED) visit and assess factors associated with analgesia use in pediatric patients with isolated long-bone fractures.

METHODS: This retrospective cohort study of patients aged 0 to 15 years with a diagnosis of an isolated long-bone fracture was conducted at a single, level I pediatric trauma center. Patients included were treated in the ED within 12 hours of injury and subsequently admitted to the hospital from January 2005 through August 2007. Pain medication received within the first hour after ED arrival was categorized based on prespecified standard doses as follows: adequate, inadequate, and no pain medication received. Cumulative logistic regression analysis assessed factors associated with analgesia use.

RESULTS: There were 773 patients with isolated long-bone fracture included in the analysis. Overall, 10% of patients received adequate pain medicine; 31% received inadequate medicine; and 59% received no pain medicine within 1 hour of ED arrival. In multivariable analysis, children with younger age, longer time from injury to ED arrival, closed fractures, and upper-extremity fractures were less likely to receive adequate pain medicine during the ED visit. Of those transported by emergency medical services directly from the scene to the ED, 9 (10%) of 88 were given pain medication during transport.

CONCLUSIONS: Pain management in pediatric patients following a traumatic injury has been recognized as an important component of care. This study suggests that alleviation of pain after traumatic injury requires further attention in both the prehospital and ED settings, especially among the youngest children.

A few interesting items jump out when reviewing this study. First, only 10% of patients were treated with adequate amounts of analgesia. Second, 59% of patients received no pain management within the first hour of arriving. Just to review, that’s 59% of patient 15 years and younger with long bone fractures receiving no pain medication whatsoever. Finally, only 10% of patients arriving via EMS were given any pain medication at all. There was no analysis performed on the adequacy of EMS dosing. To review, that means that EMS did not give pain medication to 90% of pediatric patient with long bone fractures. In short, this is unacceptable.

The researchers looked at root cause and found the expected variables: younger age, upper extremity fractures and closed fractures resulted in lower quantities of pain medication. The EMS-related finding, however, is what upsets me the most about this paper. If my son breaks an arm or a leg, the paramedics had better intend on giving him pain medication. Same with the ED staff.

So what about you? Do you treat pediatric patients as aggressively for pain as you do adults? What about your co-workers? What are some of the things that keep you from treating pediatrics aggressively? Let me know in the comments.

http://combatdoc-combatdoc.blogspot.com/ CombatDoc

As a whole the majority of prehospital providers under medicate for pain all the time. As a whole our standing orders nationwide demand that we under medicate for pain control.

All the time I see a failure to repeat doses of pain meds in all patients when it is indicated. Outside of burns I lost the ability to use sedation on top of the pain control at the last standing orders changes. If I bring in a child still in pain it is because of the medical directors that do not trust EMS and not because I wanted to…
- http://510medic.com 510medic
  
  Thanks for the comment. I absolutely agree that in many systems the limiting factor is the level of pain management allowed by medical directions. I’ve definitely seen this, as you have, in regards to simultaneous administration of narcotics and sedatives. Interestingly, though, I have worked in systems with generous standing orders for pediatric pain management and while the rates may have been better than 10%, it wasn’t by much. I would hazard the guess that the attitudes discovered in this study extend to EMS somewhat universally.
  The really interesting take home from this study, however, is that in the emergency department, where physicians can order whatever they want, pediatrics still aren’t being treated aggressively. Couple that attitude with restrictive protocols and you can see how we find ourselves in the situation we’re in.
http://everydayemstips.com Greg Friese

Thanks for bringing this article to our attention. Did the authors have any comment about usage of non-pharmacological pain management such as splinting, ice, or reassurance?
- http://510medic.com 510medic
  
  That a great point Greg. Unfortunately I only have access to the abstract. It’s an interesting discussion to think about how first-aid level skills like splinting, ice and reassurance are often overlooked by advanced level providers (paramedic, RN, MD, etc.). The mere fact that the study focused so heavily on analgesia may not paint an accurate picture of the level of relief or pain treatment the patients received. That being said, the injuries we’re talking about would likely have benefited from narcotic administration in addition to basic pain management techniques.
MedicSBK

I think that there are a few factors at work here. First off, there is the current medication shortage that we are all dealing with nation wide. For fear of spilling worms all over your blog, I’ll stay away from that one..

Secondly, I agree with Greg.. Ice, splinting, etc needs to be explored..

Thirdly, I think that there is a certain populace in EMS, especially in the over crowded ER city settings, that see it as partially their responsibility to help triage patients. That is to say, “St. Somewhere’s ER was packed last time I was there, and they are the only pediatric receiving center. I could medicate this child, but he could possibly take up a bed that someone else needs more.”

In that inner city setting, many paramedics feel the need to function in that constant state of overload, almost as if they are part of a 500,000 person MCI…

Also, like it or not, pain management is new to EMS. I mean, it has been around for a while, but the focus on it is a new thing. People are still becoming comfortable with it, and thanks to articles like this one, maybe they will realize what they are doing wrong.

Scott
- http://510medic.com 510medic
  
  I know you’re not saying this for your own practice Scott, but the idea of “someone needs this more than this patient” is not in line with what we do. Sometime, down the road, I hope that we are in a place when EMS practitioners are able to make critical decisions about destination necessity but the fact is we aren’t there now. If your patient can benefit from treatment, in this case pain management, do it. Bed control shouldn’t enter into the equation because we don’t have the training to make that decision correctly.
Michael Gallagher

Unreal. Formerly working as a critical care flight paramedic and subsequently returning to full time urban EMS, I find myself questioning the “bell curve”. For those who follow the analagy, one side of the bell has become quite heavy in regard to emergency care, both pre-hospitally and ED. With that said, the ED findings in this study are beyond negligent and/or malpractice and assuming the “level 1 pediatric trauma center” is also the same location providing pre-hospital direction to the providers serving the study group (at least the same geographical location) the paramedics care is to be expected (unfortunately). I’ll have to access this study now becuase the curiosity is overwhelming regarding what defined adequate vs inadequate. I am truly surprised the study was submitted for publication. I’ll assume they are being humble and falling on their swords or possibly the primary author accomplished his goal of instituting immediate change.
- http://510medic.com 510medic
  
  I do agree that studies such as this one are likely targeted to light a fire under someone’s behind.

Adequacy of Pain Management in Children with Long Bone Fractures

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