Relationship between acute morphine and the course of PTSD in children with burns

Treatments for common psychiatric conditions among children and adolescents during acute rehabilitation and reintegration phases of burn injury

Advances in critical care and surgical management during the last 20 years have decreased mortality rates among children with severe burn injuries. This improved survival rate has prompted researchers to study the psychological aspects of recovering from a burn injury. Initially research focused primarily on epidemiology, prevention and descriptions of the psychological phenomenon experienced by the children and adolescents. Whereas previously interventions were often utilized during the acute phases of burn injury without knowledge of the long-term effects, more recently, priorities have shifted to include long-term treatment outcome studies. The purpose of this paper is to review and discuss the current evidence-based techniques and their efficacy in the treatment of common psychological and psychiatric conditions among children and adolescents during the three major phases of burn injury.

Psychiatric disorders in long-term adjustment of at-risk adolescent burn survivors

This study investigated the point prevalence of psychiatric disorders among adolescent long-term burn survivors. Psychiatric symptoms and diagnoses were assessed in 50 youth (30 males, 20 females) characterized as troubled by their parent or guardian on the Child Behavior Checklist from a sample of 93 adolescent burn survivors. Those selected for further evaluation had a mean age at time of burn injury of 4.5 +/- 3.7 years and the mean age at time of diagnostic interview was 14.9 +/- 1.6 years. The average burn injury size among participants was 42 +/- 25% total body surface area. Psychiatric diagnoses were assessed with the computerized diagnostic interview schedule for children. Just over half of these youth (52%) met criteria for one or more psychiatric disorders and many had two or more diagnoses (22%). The most common psychiatric diagnoses were anxiety disorders (36%), followed by substance use (18%) and disruptive behavior disorders (14%). In comparison to previous reports, this study found lower rates of current psychiatric disorders in adolescent burn survivors, even though the participants were considered troubled by a parent. Although there were lower rates of anxiety disorders, especially posttraumatic stress disorder, there were higher rates of substance use disorders and a shift in type of behavior disorders in contrast to previous reports. Although there are limitations in such comparisons, this may indicate changes in the risk factors encountered by adolescent survivors of burn injury.

A study of the protective function of acute morphine administration on subsequent posttraumatic stress disorder

BACKGROUND

To index the extent to which acute administration of morphine is protective against development of posttraumatic stress disorder (PTSD).

METHODS

Consecutive patients admitted to hospital after traumatic injury (n=155) were assessed for current psychiatric disorder, pain, and morphine dose in the initial week after injury and were reassessed for PTSD and other psychiatric disorders 3 months later (n=120).

RESULTS

Seventeen patients (14%) met criteria for PTSD at 3 months. Patients who met criteria for PTSD received significantly less morphine than those who did not develop PTSD; there was no difference in morphine levels in those who did and did not develop major depressive episode or another anxiety disorder. Hierarchical regression analysis indicated that PTSD severity at 3 months was significantly predicted by acute pain, mild traumatic brain injury, and elevated morphine dose in the initial 48 hours after trauma, after controlling for injury severity, gender, age, and type of injury.

CONCLUSIONS

Acute administration of morphine may limit fear conditioning in the aftermath of traumatic injury and may serve as a secondary prevention strategy to reduce PTSD development.

Psychological rehabilitation of pediatric burn patients

Pediatric burns are devastating injuries, physically and emotionally; however, with progressive medical treatment even with the most severe burns, more burn patients are surviving. This leads to the introduction of a new area of medicine including the psychologic rehabilitation requiring the attention of reconstructive surgeons. Successful psychologic rehabilitation depends on a coordinated interdisciplinary burn care team, family, and the school environment, as well as the child.

[Psychotherapy for traumatized children and adolescents--cognitive-behavioral treatments]

According to cognitive-behavioral models, both the avoidance of trauma-associated cues, as well as cognitive distortions of the trauma and the initial symptoms thereof lead to and subsequently maintain traumatic disorders. Trauma-focused cognitive behavioral therapy often starts with stabilizing interventions such as relaxation training. The main intervention consists of exposure to external trauma-associated cues (exposure in vivo) and to mental trauma reminders (exposure in sensu). Cognitive interventions aim to modify feelings of exaggerated guilt and shame. Of the different cognitive-behavioral programmes validated, trauma-focused cognitive-behavioral therapy yields the best evidence, particularly in the treatment of sexually abused children and adolescents.

Burns: what are the pharmacological treatment options?

BACKGROUND

Many advances have been made in the understanding and management of burn injury, dramatically increasing pharmacological decision options for burn care professionals. Since burn injury is so multi-faceted, these advances cross many injury processes, both acute and chronic.

OBJECTIVE

The purpose of this review was to highlight the advances and decision options across the entire scope of the burn injury process. The burn-related processes with the most significant pharmacological options of approved products are highlighted.

METHODS

The scope of the current research is the most pertinent literature, which has been summarized with the addition of a personal perspective.

RESULTS/CONCLUSIONS

Many advances over the past decade in multiple fields have made pharmacological options plentiful in burn care. That said, there are many problems for the burn patient which persist, making burn injury still the most severe form of trauma. These issues range from management of a catabolic state with involuntary weight loss in the critical burn to severe itching in the rehabilitating patient. There are also many more treatment options available today. Two key reasons stand out as the most prominent. One reason is the fact that burn care has become much more proactive, by searching out new approaches to solve old problems. Now the treatment approach is altering its focus on manipulating the course of a burn. Examples include the use of temporary skin substitutes in partial thickness or second degree burns, decreasing pain and increasing the healing rate. Another is the use of slow release silver dressing as the topical burn wound antimicrobial of choice, markedly reducing discomfort, the need for dressing changes and an overall decrease in infection. In larger, deeper burns, the approach has changed from the chronic management of an open burn wound to rapid excision and wound closure, eliminating the burn as a source of complications. In addition, there has been a very aggressive approach to controlling the profound hypermetabolic, catabolic response to burns, rather than simply treating the outcome of this predictable post-burn complication. Approaching psychosocial stress again by prevention rather than treatment of established problems is another example. The second reason for increased options and differences in management involves the mindset of those individuals taking care of burns. Tremendous differences in experience are involved in decision-making. Different opinions are based on the expertise and also the personal preferences of those managing the burn.

Ketamine aggravates symptoms of acute stress disorder in a naturalistic sample of accident victims

The glutamatergic N-methyl-D-aspartate receptor antagonist ketamine produces transient dissociative states and alters cognitive functioning in healthy humans, thus resembling the core symptoms of acute and chronic post-traumatic stress disorder (PTSD). First evidence exists that the common use of the analgesic and sedative properties of ketamine during emergency care correlates with sustained symptoms of PTSD in accident victims. The aim of the present study was to examine whether ketamine administration after moderate accidental trauma modulates dissociation and other symptoms of acute stress disorder (ASD) in the direct aftermath of the event. Accident victims were screened within the third day after admission to hospital for symptoms of ASD (Peritraumatic Dissociative Experiences Questionnaire, ASD Scale) and prior stressful life events (Traumatic Life Events Questionnaire). Subjects had received a single or fractionated dose of either racemic ketamine (n=13), opioids (n=24) or non-opioid analgesics (n=13) during initial emergency treatment. There were no significant differences between medication groups in demographic and clinical characteristics such as injury severity or prior traumatization. With respect to ASD symptomatology three days post-event there were significant associations between ketamine analgosedation and increased symptoms of dissociation, reexperiencing, hyperarousal and avoidance relative to the comparison groups.Growing evidence exists that ketamine might modulate or aggravate early post-traumatic stress reactions when given in the acute trauma phase, which in turn might contribute to long-lasting symptomatology.

The impact of unintentional pediatric trauma: a review of pain, acute stress, and posttraumatic stress

This article reviews current research on acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) resulting from pediatric simple (i.e., single, unpredictable, and unintentional) physical injury and how pain may act as both a trigger and a coexisting symptom. Although several studies have explored predictors of ASD and PTSD, as well as the relationship between these conditions in adults, there is less research on ASD and PTSD in children and adolescents. This review highlights the importance of early detection of pain and acute stress symptoms resulting from pediatric unintentional physical injury in the hopes of preventing long-term negative outcomes, such as the potential development of PTSD and associated academic, social, and psychological problems.

What are the psychiatric sequelae of burn pain?

Burn injuries and their subsequent treatment cause one of the most excruciating forms of pain imaginable. Practitioners in the field have been concerned about the suboptimal management of acute pain in this population. Recent studies have shown that greater levels of acute pain are associated with negative long-term psychologic effects such as depression, suicidal ideation, and post-traumatic stress disorder for as long as 2 years after the initial burn injury. Research in other non-burn trauma populations has also pointed to the potential for unmanaged acute pain to delay wound healing and lead to other medical complications, such as infection and extended hospitalization period. The concept of allostatic load is presented as a potential explanation for the relationship between acute pain and subsequent psychologic and physiologic outcomes. A biopsychosocial model is also presented as a means of obtaining better inpatient pain management and helping to mediate this relationship.

Acute stress disorder and posttraumatic stress disorder: a prospective study of prevalence, course, and predictors in a sample with major burn injuries

This is one of the largest prospective studies of patients with major burn injuries to use psychometrically sound methods to track and predict posttraumatic stress disorder (PTSD) across 2 years after burn. The principal objectives were to investigate the utility of self-report measures in detecting acute stress disorder (ASD) and PTSD, and in tracking and predicting PTSD. Participants were adult patients admitted for treatment of a major burn injury. The Stanford Acute Stress Reaction Questionnaire (SASRQ) was used to assess ASD symptomatology at discharge (n = 178), and the Davidson Trauma Scale was used to assess PTSD symptoms at scheduled follow-ups at 1 (n = 151), 6 (n = 111), 12 (n = 105), and 24 (n = 71) months after burn. The prevalence of in-hospital ASD was 23.6%, and 35.1, 33.3, 28.6, and 25.4% of the participants met PTSD criteria at 1, 6, 12, and 24 months, respectively. Clinically significant and reliable change in PTSD symptomatology during the 24 months was uncommon. SASRQ diagnostic cutoff and total scores each robustly predicted PTSD at the first three follow-ups and all four follow-ups, respectively. A SASRQ empirically derived cutoff score (> or =40) yielded moderate-high sensitivities (0.67-0.71) and specificities (0.75-0.80), and predicted PTSD at each follow-up. In conclusion, ASD and PTSD are prevalent following major burn injuries, ASD symptomatology can reliably predict PTSD up to 24 months later, and, once established, PTSD usually persists. Research is needed to determine whether early recognition and treatment of persons with in-hospital ASD can improve long-term outcomes.

Psychobiology of posttraumatic stress disorder in pediatric injury patients: A review of the literature

Research suggests that about a quarter to a third of children with traffic-related injuries develop posttraumatic stress disorder (PTSD). Early symptoms of PTSD have been found to predict poor mental and physical outcome in studies of medically injured children. However, these symptoms are rarely recognized by physicians who provide emergency care for these children. In addition, there is insufficient knowledge about predictors of posttraumatic stress symptoms in this specific pediatric population. Early identification of those children at particular risk is needed to target preventive interventions appropriately. After some introducing remarks on the classification and the nature of posttraumatic stress reactions, current research findings on psychological and biological correlates of PTSD in pediatric injury patients are presented. The particular focus in this paper is on the neurobiological mechanisms that influence psychological responses to extreme stress and the development of PTSD. Continued study of the psychobiology of trauma and PTSD in pediatric injury patients, both in terms of neurobiology and treatment is needed.

Longitudinal association between infant disorganized attachment and childhood posttraumatic stress symptoms

The purpose of this study was to evaluate whether children with a history of disorganized attachment in infancy were more likely than children without a history of disorganized attachment to exhibit symptoms of posttraumatic stress disorder (PTSD) at school age following trauma exposure. The sample consisted of 78 8.5-year-old children from a larger, ongoing prospective study evaluating the effects of intrauterine cocaine exposure (IUCE) on children's growth and development from birth to adolescence. At the 12-month visit, children's attachment status was scored from videotapes of infant-caregiver dyads in Ainsworth's strange situation. At the 8.5-year visit, children were administered the Violence Exposure Scale-Revised, a child-report trauma exposure inventory, and the Diagnostic Interview for Children and Adolescents by an experienced clinical psychologist masked to children's attachment status and IUCE status. Sixteen of the 78 children (21%) were classified as insecure-disorganized/insecure-other at 12 months. Poisson regressions covarying IUCE, gender, and continuity of maternal care indicated that disorganized attachment status at 12 months, compared with nondisorganized attachment status, significantly predicted both higher avoidance cluster PTSD symptoms and higher reexperiencing cluster PTSD symptoms. These findings suggest that the quality of early dyadic relationships may be linked to differences in children's later development of posttraumatic stress symptoms following a traumatic event.

Asthma severity and PTSD symptoms among inner city children: a pilot study

Although the association between posttraumatic stress symptoms and asthma severity among children has been hypothesized, it has yet to be explored rigorously. This study sought to describe the posttraumatic stress symptoms of children with asthma and explore the relationship between asthma severity and posttraumatic stress symptoms in an inner city sample with high rates of traumatic exposures. Children aged 7 to 17 years, with a clinician-defined asthma diagnosis, were recruited from an inner city outpatient asthma clinic. Caregivers completed measures assessing the child's asthma and posttraumatic stress symptoms and health care utilization. Children also completed measures of asthma, posttraumatic stress symptoms, and asthma-related quality of life. In all, 24 children-caregiver dyads were enrolled. The sample was 79% male and 83% African American, and the mean age was 11 years. Overall the sample had severe asthma, with 33% having been hospitalized over the past year. In addition, 25% of the sample met Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for the diagnosis of posttraumatic stress disorder, and 74% of the sample experienced a traumatic event. Posttraumatic stress disorder symptoms were found to be significantly related to asthma severity, quality of life, and health care utilization. Assessing for and treating posttraumatic stress symptoms among children with severe asthma may help to improve their asthma course and quality of life. Further research should explore this relationship and related treatment implications.

A nationwide US study of post-traumatic stress after hospitalization for physical injury

BACKGROUND

Injured survivors of individual and mass trauma are at risk for developing post-traumatic stress disorder (PTSD). Few investigations have assessed PTSD after injury in large samples across diverse acute care hospital settings.

METHOD

A total of 2931 injured trauma survivors aged 18-84 who were representative of 9983 in-patients were recruited from 69 hospitals across the USA. In-patient medical records were abstracted, and hospitalized patients were interviewed at 3 and 12 months after injury. Symptoms consistent with a DSM-IV diagnosis of PTSD were assessed with the PTSD Checklist (PCL) 12 months after injury.

RESULTS

Approximately 23% of injury survivors had symptoms consistent with a diagnosis of PTSD 12 months after their hospitalization. Greater levels of early post-injury emotional distress and physical pain were associated with an increased risk of symptoms consistent with a PTSD diagnosis. Pre-injury, intensive care unit (ICU) admission [relative risk (RR) 1.17, 95% confidence interval (CI) 1.02-1.34], pre-injury depression (RR 1.33, 95% CI 1.15-1.54), benzodiazepine prescription (RR 1.46, 95% CI 1.17-1.84) and intentional injury (RR 1.32, 95% CI 1.04-1.67) were independently associated with an increased risk of symptoms consistent with a PTSD diagnosis. White injury survivors without insurance demonstrated approximately twice the rate of symptoms consistent with a diagnosis of PTSD when compared to white individuals with private insurance. By contrast, for Hispanic injury survivors PTSD rates were approximately equal between uninsured and privately insured individuals.

CONCLUSIONS

Nationwide in the USA, more than 20% of injured trauma survivors have symptoms consistent with a diagnosis of PTSD 12 months after acute care in-patient hospitalization. Coordinated investigative and policy efforts could target mandates for high-quality PTSD screening and intervention in acute care medical settings.

Brief Report: Quality of Life Is Impaired in Pediatric Burn Survivors with Posttraumatic Stress Disorder

OBJECTIVE

This study assessed health-related quality of life (HRQOL) and posttraumatic stress disorder (PTSD) in pediatric burn survivors and examined associations between PTSD and HRQOL.

METHODS

Forty-three burn survivors, ages 7-16 years, were interviewed at an average of 4.4 years after their accident using the Clinician-Administered PTSD Scale for Children and Adolescents and the TNO-AZL Child Quality of Life Questionnaire.

RESULTS

Eight children (18.6%) met DSM-IV criteria for current PTSD. While most dimensions of HRQOL were within normal limits, social functioning was impaired. Severity of PTSD was significantly associated with physical, cognitive, and emotional dimensions of HRQOL. Children with PTSD reported an impaired overall HRQOL and limited physical (e.g., more bodily complaints) and emotional functioning (e.g., more feelings of sadness).

CONCLUSIONS

This study provides tentative evidence for a considerably high prevalence of PTSD in pediatric burn survivors and for a negative association between PTSD and HRQOL.

Management of pain after burn injury

PURPOSE OF REVIEW

Burn pain is often under treated. Burn patients suffer from daily background pain as well as procedural pain. Direct mechanical and chemical stimulation to peripheral nociceptors, peripheral- and central sensitization contribute to the pathophysiology of pain. The purpose of this review is to discuss the current management of burn pain and also to stimulate future studies.

RECENT FINDINGS

Background pain is best treated with mild to moderate potent analgesics administered regularly to maintain a steady plasma drug concentration. Procedural pain should be treated vigorously with intravenous opioids, local or even general anesthesia if needed. Opioids are the mainstay of treatment for severe acute pain. PCA should be used wherever applicable. Further opioids should not be substituted by high dose NSAIDs in the management of procedural pain. Hypnosis, therapeutic touch, massage therapy, distracting techniques and other behavioral cognitive techniques have demonstrated some intriguing impact on acute as well as chronic burn pain treatment.

SUMMARY

There is no clear evidence to show that the use of opioids in acute pain may increase the likelihood of developing opioid dependency. Thus, pain after burn injury should be aggressively treated using pharmacologic and non-pharmacologic approaches. Further controlled studies are yet to be conducted to define appropriate treatments for different burn patients and to establish standard treatment protocols for burn pain.

Altered central micro-opioid receptor binding after psychological trauma

BACKGROUND

Functional neuroimaging studies have detected abnormal limbic and paralimbic activation to emotional probes in posttraumatic stress disorder (PTSD), but few studies have examined neurochemical mechanisms that underlie functional alterations in regional cerebral blood flow. The mu-opioid neurotransmitter system, implicated in responses to stress and suppression of pain, is distributed in and is thought to regulate the function of brain regions that are implicated in affective processing.

METHODS

Here we examined the micro-opioid system with positron emission tomography and the micro-opioid receptor-selective radiotracer [11C] carfentanil in 16 male patients with PTSD and two non-PTSD male control groups, with (n = 14) and without combat exposure (n = 15). Differences in micro-opioid receptor binding potential (BP2) were detected within discrete limbic and paralimbic regions.

RESULTS

Relative to healthy controls, both trauma-exposed groups had lower micro-opioid receptor BP2 in extended amygdala, nucleus accumbens, and dorsal frontal and insular cortex but had higher BP2 in the orbitofrontal cortex. PTSD patients exhibited reduced BP2 in anterior cingulate cortex compared with both control groups. Micro-opioid receptor BP2 in combat-exposed subjects without PTSD was lower in the amygdala but higher in the orbitofrontal cortex compared with both PTSD patients and healthy controls.

CONCLUSIONS

These findings differentiate the general response of the micro-opioid system to trauma from more specific changes associated with PTSD.

Palliative care in the surgical intensive care unit: where least expected, where most needed

Despite dramatic improvements in survival from a broad range of afflictions seen in the surgical critical care unit, the problem of suffering in its many forms and its long-term consequences will remain as long as mortality characterizes the human condition. Palliative care in the surgical intensive care unit is an extension of time-honoured surgical principles and traditions that aims to relieve suffering and improve quality of life associated with serious illness as an end in it self or as part of treatment to save and prolong life.

Burn injury pain: the continuing challenge

The development of more effective methods of relieving pain associated with burn injury is a major unmet medical need. Not only is acute burn injury pain a source of immense suffering, but it has been linked to debilitating chronic pain and stress-related disorders. Although pain management guidelines and protocols have been developed and implemented, unrelieved moderate-to-severe pain continues to be reported after burn injury. One reason for this is that the intensity of pain associated with wound care and rehabilitation therapy, the major source of severe pain in this patient population, varies widely over the 3 phases of burn recovery, making it difficult to estimate analgesic requirements. The effects of opioids, the most commonly administered analgesics for burn injury procedural pain, are difficult to gauge over the course of burn recovery because the need for an opioid may change rapidly, resulting in the overmedication or undermedication of burn-injured patients. Understanding the mechanisms that contribute to the intensity and variability of burn injury pain over time is crucial to its proper management. We provide an overview of the types of pain associated with a burn injury, describe how these different types of pain interfere with the phases of burn recovery, and summarize pharmacologic pain management strategies across the continuum of burn care. We conclude with a discussion and suggestions for improvement. Rational management, based on the underlying mechanisms that contribute to the intensity and variability of burn injury pain, is in its infancy. The paucity of information highlights the need for research that explores and advances the identification of mechanisms of acute and chronic burn injury pain.

PERSPECTIVE

Researchers continue to report that burn pain is undertreated. This review examines burn injury pain management across the phases of burn recovery, emphasizing 3 types of pain that require separate assessment and management. It provides insights and suggestions for future research directions to address this significant clinical problem.

Risperidone treatment of preschool children with thermal burns and acute stress disorder

Pharmacologic treatment of acute stress disorder (ASD) is a novel area of investigation across all age groups. Very few clinical drug trials have been reported in children and adolescents diagnosed with ASD. Most of the available, potentially relevant, data are from studies of adults with posttraumatic stress disorder (PTSD). The atypical antipsychotic agents have been reported to be effective as an adjunctive treatment for adults with PTSD. There have been a limited number of studies published regarding atypical antipsychotic treatment of PTSD in children and adolescents, and there is no current literature available on the use of these agents for children with ASD. This report describes the successful treatment of three preschool-aged children with serious thermal burns as a result of physical abuse or neglect. Each of these children was hospitalized in a tertiary-care children's hospital and was diagnosed with ASD. In all cases, risperidone provided rapid and sustained improvement across all symptom clusters of ASD at moderate dosages. Minimal to no adverse effects were reported. These cases present preliminary evidence for the potential use of risperidone in the treatment of ASD in childhood.

Posttraumatic stress symptoms in the pediatric intensive care unit

PURPOSE

Children who experience acute injury or illness severe enough to result in a pediatric intensive care unit (PICU) stay are at risk for posttraumatic stress symptoms, as are their parents. A distinction is made between injury-related traumatic events, illness-related traumatic events, and treatment-related traumatic events, all of which contribute to this risk.

CONCLUSIONS

This paper reviews what the PICU experience is like for children and their parents, the emerging literature on posttraumatic stress symptoms in PICU patients and their parents, and current knowledge regarding risk and resiliency factors for these children.

PRACTICE IMPLICATIONS

Children hospitalized in the PICU should be monitored for posttraumatic stress disorder during and after their stay. Risk and resiliency factors are a focus for practice and for future research.

Psychiatric sequelae of disasters

In addition to physical injuries, survivors of disasters also suffer psychological trauma. Resulting mental anguish and illness can be profoundly debilitating and complicate the recovery and rehabilitation process. Front-line trauma teams caring for survivors of disasters must know the risks, assessment, and appropriate response to psychological injury. This article reviews the development of understanding mental disturbance after disasters and current approaches to evaluation and treatment.

Latent difference score approach to longitudinal trauma research

In this article, the authors introduce a latent difference score (LDS) approach to analyzing longitudinal data in trauma research. The LDS approach accounts for internal sources of change in an outcome variable, including the influence of prior status on subsequent levels of that variable and the tendency for individuals to experience natural change (e.g., a natural decrease in posttraumatic stress disorder [PTSD] symptoms over time). Under traditional model assumptions, the LDSs are maximally reliable and therefore less likely to introduce biases into model testing. The authors illustrate the method using a sample of children who experienced significant burns or other injuries to examine potential influences (i.e., age of child-adolescent at time of trauma and ongoing family strains) on PTSD symptom severity over time.

Brain dysfunction in critically ill patients--the intensive care unit and beyond

Critical care physicians often find themselves prognosticating for their patients, attempting to predict patient survival as well as disability. In the case of neurologic injury, this can be especially difficult. A frequent cause of coma in the intensive care unit is resuscitation following cardiac arrest, for which mortality and severe neurologic disability remain high. Recent studies of the clinical examination, of serum markers such as neuron-specific enolase, and of somatosensory evoked potentials allow accurate and specific prediction of which comatose patients are likely to suffer a poor outcome. Using these tools, practitioners can confidently educate the family for the majority of patients who will die or remain comatose at 1 month. Delirium is a less dramatic form of neurologic injury but, when sought, is strikingly prevalent. In addition, delirium in the intensive care unit is associated with increased mortality and poorer functional recovery, prompting investigation into preventative and therapeutic strategies to counter delirium. Finally, neurologic damage may persist long after the patient's recovery from critical illness, as is the case for cognitive dysfunction detected months and years after critical illness. Psychiatric impairment including depression or post-traumatic stress disorder may also arise. Mechanisms contributing to each of these entities are reviewed.

Pain During Burn Hospitalization Predicts Long-term Outcome

Acute pain after medical procedures is often undertreated, opioid analgesics are used far too sparingly, and patients are forced to suffer needlessly as a result. Attempts to change health care practitioner behavior in the area of pain control are often futile. The purpose of the current study was to provide empirical evidence that supports the deleterious impact of acute pain. A prospective, longitudinal study was designed to assess the impact of pain during burn hospitalization on postdischarge follow-up of 122 patients. A composite score of patient ratings of procedural pain during hospitalization was composed. Regression analyses were used to compare the extent to which pain predicted long-term adjustment relative to potential competing variables such as the length of hospitalization, preinjury adjustment, and coping style. Pain during hospitalization was significantly associated with psychological adjustment at 1-month (53% return), 1-year (46% return) and 2-year (33% return) follow-up. Regression analyses indicate that pain was a stronger predictor than the size of the burn or length of hospitalization, and that this correlation could not be attributed to the patients' preinjury mental health history or coping style (for the 1-month and 1-year follow-up periods). Pain during hospitalization had a significant and enduring relationship with adjustment after burn injuries. Although causality cannot be definitively determined, the study findings provided compelling evidence for the value of controlling acute pain during hospitalization.

Separation Anxiety as a Mediator Between Acute Morphine Administration and PTSD Symptoms in Injured Children

Emerging evidence suggests that individuals who receive morphine while hospitalized demonstrate a decrease in symptoms of posttraumatic stress disorder (PTSD). However, the mechanisms of effects are not yet well understood. The goal of the current study was to examine three possible mediators for this effect. Sixty-one injured (burns, motor vehicle accidents, falls, and assaults) children were assessed during hospitalization and again 3 months post discharge. Assessment included acute and follow-up child report measures of pain, PTSD, and anxiety symptoms, as well as a medical record review for medication administration and pulse during hospitalization. Pathway analyses were conducted to test the potential mediating roles of pain reduction, noradrenergic attenuation, and separation anxiety on the association between morphine and PTSD. Results suggest that a reduction in separation anxiety may mediate the association between morphine administration and PTSD symptom reduction at 3 months. These findings have implications for our understanding of morphine's effects on psychological functioning following an acute injury and for direct clinical care.

Post-traumatic stress response to life-threatening illnesses in children and their parents

Symptoms of PTSD have been reported in response to a variety of life-threatening medical illnesses and injuries in adults and children. Emerging data suggest that children often experience medical treatment and hospitalization as traumatic, putting caregivers and medical personnel in the role of the unintended accomplice. Adequate pain control by pharmacologic and behavioral means; child and family psychological support using evidence-based CBT, dynamic psychotherapy, and other techniques; and meticulous attention to communication via a team-based approach are the cornerstones of pediatric palliative care in general and PTSD prevention and treatment in particular. Emerging evidence suggests that PTSD in life-limiting pediatric illness can be ameliorated, if not prevented, and treated when it occurs, contributing materially to the quality of life of a child and family. A landmark finding of PTSD research with medically ill children and their families is that parents are at least as symptomatic, or more, as their children, underlining the importance of a family-directed approach addressing every family mem-ber. Pediatric caregivers increasingly recognize their therapeutic role when curative therapy is no longer possible is as pivotal as in the setting of acute illness.

Psychopharmacology in pediatric critical care

Psychopharmacologic treatment in pediatric critical care requires a careful child or adolescent psychiatric evaluation, including a thorough review of the history of present illness or injury, any current or pre-existing psychiatric disorder, past history, and laboratory studies. Although there is limited evidence to guide psychopharmacologic practice in this setting, psychopharmacologic treatment is increasing in critical care, with known indications for treatment, benefits, and risks; initial dosing guidelines; and best practices. Treatment is guided by the knowledge bases in pediatric physiology, psycho-pharmacology, and treatment of critically ill adults. Pharmacologic considerations include pharmacokinetic and pharmcodynamic aspects of specific drugs and drug classes, in particular elimination half-life, developmental considerations, drug interactions, and adverse effects. Evaluation and management of pain is a key initial step, as pain may mimic psychiatric symptoms and its effective treatment can ameliorate them. Patient comfort and safety are primary objectives for children who are acutely ill and who will survive and for those who will not. Judicious use of psychopharmacolgic agents in pediatric critical care using the limited but growing evidence base and a clinical best practices collaborative approach can reduce anxiety,sadness, disorientation, and agitation; improve analgesia; and save lives of children who are suicidal or delirious. In addition to pain, other disorders or indications for psychopharmacologic treatment are affective disorders;PTSD; post-suicide attempt patients; disruptive behavior disorders (especially ADHD); and adjustment, developmental, and substance use disorders. Treating children who are critically ill with psychotropic drugs is an integral component of comprehensive pediatric critical care in relieving pain and delirium; reducing inattention or agitation or aggressive behavior;relieving acute stress, anxiety, or depression; and improving sleep and nutrition. In palliative care, psychopharmacology is integrated with psychologicapproaches to enhance children's comfort at the end of life. Defining how best to prevent the adverse consequences of suffering and stress in pediatric critical care is a goal for protocols and for new psychopharmacologic research [23,153].

The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient

This retrospective review of 286 acute pediatric burn survivors treated in 2001 evaluated the effectiveness of a pharmacotherapeutic protocol for pain, anxiety, and itching. Background pain, procedural pain, exercise pain, anxiety, incidence of acute stress disorder (ASD), and itch were measured with standardized instruments. When this review was compared to similar reviews done in 1993-1994 and 1998, a steady trend toward using more potent pain medications in this patient population is evident. While the use of acetaminophen alone decreased from 50.6% of patients in 1993-1994 and 26.3% in 1998 to 7.3% in 2001, the use of opiates increased from 44.8% in 1993-1994 and 66.9% in 1998 to 81.3% of patients in 2001. Likewise, the use of benzodiazepines for anxiety has increased from 59.8% in 1998 to 77.5% of patients in 2001. During that same period the incidence of ASD decreased from 12.1% in 1993-1994 to 8.7% of patients in 2001. For effective pain and anxiety management, the average administered dose of lorazepam and morphine also increased, providing impetus to revise the pharmacotherapeutic pain protocol. Having a standard pain protocol furnishes a framework for periodic review and facilitates updating of pain and anxiety treatment practices.

Trauma Severity Influences Acute Stress in Young Burned Children

The purpose of this study was to assess the role of trauma severity on subsequent symptoms of posttraumatic stress disorder (PTSD) and physiological reactivity in a total of 70 children, ranging from 12 to 48 months of age, who were acutely burned. Parents were interviewed shortly after the child was admitted to the hospital. PTSD symptoms were measured using the Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children and the Diagnostic Interview for Children and Adolescents. Nurses completed a questionnaire about the child's symptoms and recorded the child's physiological data throughout the hospital stay. Significant relationships were found between severity of childhood trauma and the total number of PTSD symptoms and physiological reactivity. This study supports the hypothesis that severity of trauma experienced by young children influences psychological and physiological stress indicators after burn injuries. These findings provide new directions for the assessment and prevention of PTSD in this age group.

Pain medication use among patients with posttraumatic stress disorder

The relationship of analgesic medication use with posttraumatic stress disorder (PTSD) diagnosis was investigated among a sample of 173 African Americans presenting for routine outpatient visits at an urban mental health center. Seventy-eight (43.5%) of the sample met DSM-IV PTSD criteria. Those with PTSD had significantly higher use of analgesic medication (both opiate and non-opiate), as compared with non-PTSD patients. PTSD symptoms, as measured by the Posttraumatic Symptom Scale, were significantly higher in subjects who were prescribed analgesics. The authors conclude that there may be a relationship between PTSD and use of pain medications warranting further examination of the endogenous opiate system in the pathophysiology of PTSD.

Posttraumatic stress disorder in medically ill patients: what is known, what needs to be determined, and why is it important?

Can a medical illness or its treatment qualify as an emotionally traumatic event and can it cause posttraumatic stress disorder symptoms? If so, can the view of a medical illness as a traumatic experience enhance our ability to understand patients' adjustment to illness and their emotional reactions to it? Is it important to identify posttraumatic symptoms and try to address them in medically ill patients? These questions form the backbone for this review. Because many questions remain unanswered (or the answers are not definitive yet), we concisely summarize the issues and present our own view of the most pressing questions for further research.

Acute stress symptoms in young children with burns

OBJECTIVE

Posttraumatic stress disorder symptoms are a focus of much research with older children, but little research has been conducted with young children, who account for about 50% of all pediatric burn injuries. This is a 3-year study of 12- to 48-month-old acutely burned children to assess acute traumatic stress outcomes. The aims were to (1) assess the prevalence of acute traumatic stress symptoms and (2) develop a model of risk factors for these symptoms in these children.

METHOD

Acute stress symptoms were measured using the Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children. Children's responses were then assessed, including behavior and physiological measures for developmental/functional consequences. A path analysis strategy was used to build a model of risk factors. Risk factors assessed in this model included observed pain (Visual Analogue Scale), parent symptoms (Stanford Acute Stress Reaction Questionnaire), and magnitude of trauma (total body surface area burned).

RESULTS

Of the 64 subjects meeting inclusion criteria, 52 subjects agreed to participate. These children were highly symptomatic; almost 30% of these children had acute stress symptoms. A path analysis model yielded two independent pathways to acute stress symptoms: (1) from the size of the burn to the mean pulse rate in the hospital to acute stress symptoms and (2) from the child's pain to the parents' stress symptoms to acute stress symptoms. This model accounted for 39% of the variance of acute stress symptoms and yielded excellent fit indexes.

CONCLUSIONS

A high percentage of acute stress symptoms were identified in young children with burns. A model of risk factors, including the size of the burn, pain, pulse rate, and parents' symptoms, was identified.

Determinants of Quality of Life and Role-Related Disability After Injury: Impact of Acute Psychological Responses

BACKGROUND

The factors that determine quality of life (QOL) and disability after traumatic injury are poorly understood. This study identified the unique contributions that characteristics about the injury/hospital admission and acute psychological adjustment make in determining 12-month role-related disability and QOL.

METHODS

Consecutive admissions (n = 363) to a Level I trauma service were assessed just before discharge and followed up at 12 months. Structural equational modeling was used to examine the relationships between the acute factors and 12-month outcomes.

RESULTS

Characteristics of the individual's injuries measured in the acute setting significantly predicted 12-month disability but only indirectly predicted 12-month QOL. An individual's acute psychological response directly predicted both the level of disability and QOL at 12 months.

CONCLUSIONS

Both characteristics about an individual's injury and acute psychological responses play important roles in determining later QOL and role-related disability outcomes. Trauma care systems must consider both physical and psychological injury to offer effective and comprehensive healthcare management.

Early treatment of acute stress disorder in children with major burn injury

OBJECTIVE

This study examines retrospectively the response rate of pediatric burn survivors with acute stress disorder to either imipramine or fluoxetine.

METHODS

On retrospective chart review, 128 intensive care unit patients (85 boys, 43 girls) with 52%+/- 20% total body surface area burn, length of stay of 32.8+/- 25.2 days, mean age of 9.1+/- 4.7 yrs, and age range of 13 months to 19 yrs met criteria for acute stress disorder after >or=2 days of symptoms and were treated with either imipramine or fluoxetine. If significant improvement did not occur within 7 days, the medication was either increased or switched to the other class.

RESULTS

Initially, 104 patients were treated with imipramine and 24 with fluoxetine. A total of 84 patients responded to imipramine: seven of these patients required a higher dose. A total of 18 patients responded to initial fluoxetine treatment. Of 26 nonresponders to the initial medication, 13 imipramine failures and one fluoxetine failure refused further treatment. The other 12 responded to the second medication. Therefore, 114 of 128 treated patients (89%) responded to either fluoxetine (mean dose, 0.30+/- 0.14 mg/kg) or imipramine (mean dose, 1.30+/- 0.55 mg/kg). Response was independent of sex and age but was less for those with burns of >60% total body surface area. The side effects of each medication were not significant. Most patients continued treatment for >or=3 months; some required 6 months of treatment before successful discontinuation.

CONCLUSIONS

Early treatment of acute stress disorder with either imipramine or fluoxetine is often able to reduce its symptoms. This is a review of a single hospital's experience in managing psychiatric distress in this very high-risk group of burned children. Additional clinical studies are needed before generalizing these findings.

Effects of peritraumatic ketamine medication on early and sustained posttraumatic stress symptoms in moderately injured accident victims

RATIONALE

Ketamine, an N-methyl-D: -aspartate receptor antagonist, produces transient dissociative and psychotic states in healthy humans that resemble symptoms shown by subjects with acute and chronic posttraumatic stress disorder (PTSD). Since ketamine is widely used as an analgesic and sedative in emergency care, it might be one factor triggering, modulating, or exacerbating PTSD in accident victims when given in the acute trauma phase.

OBJECTIVES

The purpose of the present study was to determine whether the peritraumatic administration of ketamine affects acute and sustained PTSD symptoms in accident victims.

METHODS

A sample of 56 moderately injured accident victims was screened retrospectively for acute (Peritraumatic Dissociative Experiences Questionnaire; Acute Stress Disorder Scale) and for current PTSD symptoms (Impact of Event Scale) approximately 1 year postaccident. All subjects had received a single or fractionated dose of either racemic ketamine (n = 17), (S)-ketamine (n = 12), or opioids (n = 27) during emergency ambulance transportation.

RESULTS

Retrospectively assessed acute symptomatology was strongly increased in (S)-ketamine subjects in terms of dissociation, reexperiencing, and avoidance, and slightly heightened in racemic ketamines. Current PTSD symptoms were substantially elevated in (S)-ketamine subjects, while there was no difference observed between opioids and racemic ketamines. Medication groups did not differ in regard to demographic variables, previous or postaccidental traumatic events, time between accident and investigation, and injury severity.

CONCLUSIONS

The data provide first evidence for a modulating effect of a single-dose ketamine on the severity and duration of posttraumatic stress symptoms in accident victims.

Incidence of and Risk Factors for Acute Stress Disorder in Children with Injuries

BACKGROUND

To assess the incidence of and risk factors for Acute Stress Disorder (ASD) in children with injuries. Numerous studies have documented the increased incidence of PTSD in those initially diagnosed with ASD. PTSD symptoms cause tremendous morbidity and may persist for many years in some children.

METHODS

Children hospitalized with one or more injuries were interviewed and assessed with the following: Child Stress Disorders Checklist (CSDC), Family Strains Scale, Brief Symptom Inventory (BSI) and Facial Pain Scale.

RESULTS

Participants included sixty-five children (ages 7-18 years). The mechanisms of injury varied (e.g. MVC, penetrating). The mean injury severity score was 8.9 +/- 7. The mean length of hospital stay was 4.6 +/- 4.6 days. Altogether, 18 (27.7%) of participants met DSM IV criteria for ASD during their acute hospital stay. Risk factors such as level of family stress, caregiver stress, child's experience of pain, and child's age were predictive of acute stress symptoms.

CONCLUSION

We have identified four risk factors of ASD that have implications for the treatment, and possibly, preventative intervention for PTSD. Further investigation and greater understanding of risk factors for ASD in children with injuries may facilitate the design of acute interventions to prevent the long-term negative outcomes of traumatic events.

Childhood post-traumatic stress disorder: an overview

This article presents an overview of post-traumatic stress disorder (PTSD) as it relates to children and adolescents. The authors provide a critical review of the pediatric PTSD literature regarding the definition, epidemiology, clinical presentation, assessment, neurobiologic foundation, and treatment of PTSD. The importance of developmental and neurobiologic factors and the uniqueness of these factors to children are emphasized.

An Integrative Model of Pediatric Medical Traumatic Stress

OBJECTIVE

To guide assessment and intervention for patients and families, a model for assessing and treating pediatric medical traumatic stress (PMTS) is presented that integrates the literature across pediatric conditions.

METHODS

A model with three general phases is outlined--I, peritrauma; II, early, ongoing, and evolving responses; and III, longer-term PMTS. Relevant literature for each is reviewed and discussed with respect to implications for intervention for patients and families.

RESULTS

Commonalities across conditions, the range of normative responses to potentially traumatic events (PTEs), the importance of preexisting psychological well-being, developmental considerations, and a social ecological orientation are highlighted.

CONCLUSIONS

Growing empirical support exists to guide the development of assessment and intervention related to PMTS for patients with pediatric illness and their parents. The need for interventions across the course of pediatric illness and injury that target patients, families, and/or healthcare teams is apparent. The model provides a basis for further development of evidence-based treatments.

[From the biology of trauma to secondary preventive pharmalogical measures for post-traumatic stress disorders]

Of all the psychological complications that an individual is likely to present with when confronted with an exceptional event, the Post-Traumatic Stress Disorder is characterized by being progressive, frequent, invalidating, strongly associated with comorbidity, and having the tendency to become chronic if it is not detected clinically. By definition, it is threatening and produces an intense fear reaction. The traumatic event is a situation of extreme stress, not only capable of altering the physical and psychological homeostasis of the individual, but is also recognized as determinant in the aetiopathology of complications. The intensity of this distress can be identified clinically and physiologically, and is currently considered as an important risk factor for the development of PTSD later on, together with other pre-, peri- and post-traumatic factors. In fact, the most studied field is the therapeutic approach, in particular drug treatment, of the fully-constituted disorder, although this actually represents tertiary prevention. Even though primary prevention seems to concern Medicine very little, any prospect of performing secondary prevention should begin by rapid identification of the risk or vulnerability factors and should allow a population at risk from developing complications to be defined. Its potential therapeutic impact brings together psychotherapeutic and drug treatment, since it is only this combination that seems able to allow the most favourable clinical outcome to be achieved for an individual, who is confronted by an out-of-the-ordinary event. The aims of secondary prevention strategies are, for example, to reduce the incidence of acute PTSD in patients seen following the event. The benefits for the individual and for the society can easily be measured in terms of the consequences on his/her social, professional and family life, or in terms of cost. The usefulness of this prevention can also be measured by the possible ways that other conditions, comorbid to PTSD, are controlled, such as anxiety disorders, depression and substance abuse, for example. Secondary prevention strategies may also be aimed at determining the therapeutic impact, by preventing or moderating the appearance of an acute stress, or even by contributing in avoiding the onset of chronic PTSD. Psychopharmacology of the immediate and post-immediate disorders, however, remains a field which has been studied very little. Reduction or control of the high, prolonged level of hyperarousal phenomena or hypersensitization of the hypothalamo-pituitary axis, would contribute to the comfort of the individual, and would participate in the prevention of PTSD. Based on current knowledge of the neurobiology of trauma, we look into the existing and potential pharmacological possibilities. Even though benzodiazepines tend to have an important role, knowledge of other drugs and therapeutic groups is rapidly increasing. In this review, we will see that the efficacy of anti-adrenergic drugs and certain other anxiolytics is now well-documented, this opening the door to their use in the future. Other drug groups offer interesting, well-proven approaches, such as serotoninergic drugs, CRF or NPY antagonists, NMDA antagonists, anticonvulsants or other GABAergic agents. In view of this disorder, which represents a true public health problem, we consider that it is now possible to widen the horizons of our drug therapy, in combination with any necessary psychotherapeutic treatment, to reach the heart of the traumatic event, that often upsets the victims, both by the psychological suffering it induces, and the loss of his/her social, family and professional references and support structures.