Adequacy of Pain Management in Children with Long Bone Fractures
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.