Analgesia for the Pediatric Trauma Patient: Primum Non Nocere?

Analgesia and Sedation of Pediatric Patients with Major Trauma in Pre-Hospital and Emergency Department Settings-A Narrative Review

Children who sustain major injuries are at risk of receiving insufficient pain relief and sedation, which can have physical and psychological repercussions. Heightened emotional distress can increase the likelihood of developing symptoms of post-traumatic stress. Providing sufficient analgesia and sedation for children with major trauma presents specific challenges, given the potential for drug-related adverse events, particularly in non-intubated patients. The current literature suggests that a relatively low percentage of pediatric patients receive adequate analgesia in pre-hospital and emergency department settings following major trauma. There are only sparse data on the safety of the provision of analgesia and sedation in children with major trauma in the pre-hospital and ED settings. The few studies that examined sedation protocols in this context highlight the importance of physician training and competency in managing pediatric airways. There is a pressing need for prospective studies that focus upon pediatric major trauma in the pre-hospital and emergency department setting to evaluate the benefits and risks of administering analgesia and sedation to these patients. The aim of this narrative review was to offer an updated overview of analgesia and sedation management in children with major trauma in pre-hospital and ED settings.

Effect of a Computerized Reminder on Splinting of Pediatric Upper Limb Fractures in the Emergency Department

OBJECTIVE

The primary objective was to assess if a computerized pop-up reminder increased splint application before X-ray in pediatric emergency department patients with deformed upper limb fractures. The secondary objective was to evaluate whether this same reminder improved pharmaceutical analgesia provision in this population.

METHODOLOGY

This was a prospective study of 518 pediatric emergency department patients with upper limb fractures after the implementation of a computerized pop-up reminder to give analgesia and apply a splint. The records of those with fractures requiring manipulation were identified and reviewed for data on demographics, clinical characteristics, splint application, and analgesic use. These data were compared with that in a previous retrospective study of 1407 patients in the same population before implementation of the computerized reminder.

RESULTS

There were 86 patients with upper limb fractures requiring manipulation identified during the study period. After the computerized intervention, splint application rates improved from 22% to 49% (P = <0.001). There was no significant change to analgesia provision in the first hour after presentation.

CONCLUSIONS

A computerized reminder at the point of X-ray ordering significantly improved splint application rates for children with deformed upper limb fractures, though it did not affect pharmaceutical analgesia provision. The computerized pop-up is cheap to implement, easy to use, and potentially transferrable to other institutions and for other uses.

Analgesia in the management of paediatric and adolescent trauma during the resuscitative phase: the role of the pediatric trauma centre

BACKGROUND

The objective of this study was to evaluate the use of analgesia in the resuscitative phase of severely injured children and adolescents.

METHODS

A retrospective cohort of paediatric (age<18 years), severely injured (ISS≥12) patients were identified from the London Health Sciences Centre's Trauma Registry from 2007 to 2010. Variables were compared between Analgesia and Non-analgesia groups with Pearson Chi-square and Mann-Whitney U tests. Resuscitative analgesia use was assessed through multivariable logistic regression controlling for age, gender, mechanism, arrival and Trauma Team Activation (TTA).

RESULTS

Analgesia was used in 32% of cases. Univariate analysis did not reveal any differences in gender, age, injury type, injury profile and arrival patterns. Significant differences were found with analgesia used more frequently in patients injured in a motor vehicle collision (58% vs. 42%, p=0.026) and having parents in the resuscitation room (17% vs. 6%, p=0.01). Analgesia patients were more injured (median ISS 22 vs. 17, p=0.027) and had 2.25 times more TTA (39% vs. 17%). Logistic regression revealed patients arriving directly to a trauma centre had a higher incidence of receiving analgesia (OR 2.01, 95% CI: 1.03-3.93), as did TTA (OR 2.18, 95% CI: 1.01-4.73) and having parents in resuscitation room (3.56, 95% CI: 1.23-10.33). Narcotics were most commonly used (85%), followed by benzodiazepines (16%), with 66% given during the primary survey.

CONCLUSION

Use of analgesia is important in the acute management of paediatric trauma. Direct presentation to a level I trauma centre, TTA and the presence of parents lead to higher appropriate use of analgesia in paediatric trauma resuscitation.