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

Surgical and psychosocial factors related to Pediatric Medical Traumatic Stress (PMTS) in children following surgery: a follow-up study

INTRODUCTION

Surgical procedures in children involve significant psychological traumatic stress leading to the development of psychologic distress and dysfunction after surgery. Pediatric medical traumatic stress (PMTS) ensues from negative medical experiences which is a trauma that can have a devastating effect on children and their families. Awareness and early identification are important to provide psychological intervention at the correct time.

AIMS AND OBJECTIVES

This study aims to determine the prevalence of PMTS along with the associated surgical and psychosocial factors involved in pediatric surgical patients at our institute.

METHODS

We included patients admitted to the pediatric surgery ward, for elective or emergency surgeries, and a three-point assessment was done. It was done pre-surgery, at 1 month for diagnosis of PMTS, and at 3 months for any spontaneous resolution. Along with we recorded data regarding surgical and psychosocial factors in play for each child.

RESULTS

A PMTS prevalence of 16.26% was seen in the age group of 1 to 7 years and 12.64% in 8 to 18 years on evaluation at 1 month after surgery. A significant association was calculated with factors like duration of surgery, duration of hospital stay, staged approach of surgery, malignancy or congenital anomalies, postoperative pain, postoperative complications, multiple admissions, creation of stoma, need for additional interventions on follow-up, parental anxiety, and socioeconomic status. A significant spontaneous resolution at 3 months was also noted.

CONCLUSION

With this study we can establish a significant prevalence of PMTS in pediatric patients undergoing surgery and the significantly associated determinants have been identified. The healthcare team as a whole can work toward reducing the risk of the development of PMTS, both in parents and children.

LEVEL OF EVIDENCE

Level II.

improving Pain mAnagement for childreN and young people attendeD by Ambulance (PANDA): protocol for a realist review

Background

Each year in England, 450,000 children and young people (CYP) under 18 years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted. Studies have shown that prehospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance. Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP.

Methods

A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT): develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening: conduct a thorough search of relevant research databases and other literature sources and perform screening in duplicate; 3) Relevance and rigour assessment: assess documents for relevance and rigour in duplicate; 4) Extracting and organising data: code relevant data into conceptual "buckets" using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement: utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual "buckets", test and refine the IPT into a realist PT.

Conclusion

The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation.

Registration

PROSPERO Registration: CRD42024505978.

Pain after combat injury in male UK military personnel deployed to Afghanistan

BACKGROUND

Chronic pain after injury poses a serious health burden. As a result of advances in medical technology, ever more military personnel survive severe combat injuries, but long-term pain outcomes are unknown. We aimed to assess rates of pain in a representative sample of UK military personnel with and without combat injuries.

METHODS

We used data from the ADVANCE cohort study (ISRCTN57285353). Individuals deployed as UK armed forces to Afghanistan were recruited to include those with physical combat injuries, and a frequency-matched uninjured comparison group. Participants completed self-reported questionnaires, including 'overall' pain intensity and self-assessment of post-traumatic stress disorder, anxiety, and depression.

RESULTS

A total of 579 participants with combat injury, including 161 with amputations, and 565 uninjured participants were included in the analysis (median 8 yr since injury/deployment). Frequency of moderate or severe pain was 18% (n=202), and was higher in the injured group (n=140, 24%) compared with the uninjured group (n=62, 11%, relative risk: 1.1, 95% confidence interval [CI]: 1.0-1.2, P<0.001), and lower in the amputation injury subgroup (n=31, 19%) compared with the non-amputation injury subgroup (n=109, 26%, relative risk: 0.9, 95% CI: 0.9-1.0, P=0.034). Presence of at least moderate pain was associated with higher rates of post-traumatic stress (RR: 3.7, 95% CI: 2.7-5.0), anxiety (RR: 3.2, 95% CI: 2.4-4.3), and depression (RR: 3.4, 95% CI: 2.7-4.5) after accounting for injury.

CONCLUSION

Combat injury, but not amputation, was associated with a higher frequency of moderate to severe pain intensity in this cohort, and pain was associated with adverse mental health outcomes.

Prehospitalization Trauma and Physiologic Factors Associated with the Presence of Post-traumatic Stress 3 Months After PICU Discharge

BACKGROUND

Children admitted to the pediatric intensive care unit (PICU) have post-traumatic stress (PTS) rates up to 64%, and up to 28% of them meet criteria for PTS disorder (PTSD). We aim to examine whether a prior trauma history and increased physiologic parameters due to a heightened sympathetic response are associated with later PTS. Our hypothesis was children with history of prehospitalization trauma, higher heart rates, blood pressures, cortisol, and extrinsic catecholamine administration during PICU admission are more likely to have PTS after discharge.

METHODS

This is a prospective, observational study of children admitted to the PICU at an urban, quaternary, academic children's hospital. Children aged 8 to 17 years old without developmental delay, severe psychiatric disorder, or traumatic brain injury were included. Children's prehospitalization trauma history was assessed with a semistructured interview. All in-hospital variables were from the electronic medical record. PTS was present if children had 4 of the Diagnostic and Statistical Manual of Mental Disorders IV criteria for PTSD. Student's t- and chi-squared tests were used to compare the presence or absence of prior trauma and all of the PICU-associated variables.

RESULTS

Of the 110 children at baseline, 67 had 3-month follow-up. In the latter group, 46% met the criteria for PTS, mean age of 13 years (SD 3), 57% male, a mean PRISM III score of 4.9 (SD 4.3), and intensive care unit length of stay 6.5 days (SD 7.8). There were no statistically significant differences in the demographics of the children with and without PTS. The only variable to show significance was trauma history; children with prehospitalization trauma were more likely to have PTS at 3-month follow-up (P = .02).

CONCLUSIONS

Prehospitalization trauma history was associated with the presence of PTS after admission to the PICU. This study suggests future studies should shift to the potential predictive benefit of screening children for trauma history upon PICU admission.

Novel Pharmacological Targets of Post-Traumatic Stress Disorders

Post-traumatic stress disorder (PTSD) is a psychopathological condition with a heterogeneous clinical picture that is complex and challenging to treat. Its multifaceted pathophysiology still remains an unresolved question and certainly contributes to this issue. The pharmacological treatment of PTSD is mainly empirical and centered on the serotonergic system. Since the therapeutic response to prescribed drugs targeting single symptoms is generally inconsistent, there is an urgent need for novel pathogenetic hypotheses, including different mediators and pathways. This paper was conceived as a narrative review with the aim of debating the current pharmacological treatment of PTSD and further highlighting prospective targets for future drugs. The authors accessed some of the main databases of scientific literature available and selected all the papers that fulfilled the purpose of the present work. The results showed that most of the current pharmacological treatments for PTSD are symptom-based and show only partial benefits; this largely reflects the limited knowledge of its neurobiology. Growing, albeit limited, data suggests that the hypothalamic-pituitary-adrenal axis, opioids, glutamate, cannabinoids, oxytocin, neuropeptide Y, and microRNA may play a role in the development of PTSD and could be targeted for novel treatments. Indeed, recent research indicates that examining different pathways might result in the development of novel and more efficient drugs.

Derivation and validation of risk prediction for posttraumatic stress symptoms following trauma exposure

BACKGROUND

Posttraumatic stress symptoms (PTSS) are common following traumatic stress exposure (TSE). Identification of individuals with PTSS risk in the early aftermath of TSE is important to enable targeted administration of preventive interventions. In this study, we used baseline survey data from two prospective cohort studies to identify the most influential predictors of substantial PTSS.

METHODS

Self-identifying black and white American women and men (n = 1546) presenting to one of 16 emergency departments (EDs) within 24 h of motor vehicle collision (MVC) TSE were enrolled. Individuals with substantial PTSS (⩾33, Impact of Events Scale - Revised) 6 months after MVC were identified via follow-up questionnaire. Sociodemographic, pain, general health, event, and psychological/cognitive characteristics were collected in the ED and used in prediction modeling. Ensemble learning methods and Monte Carlo cross-validation were used for feature selection and to determine prediction accuracy. External validation was performed on a hold-out sample (30% of total sample).

RESULTS

Twenty-five percent (n = 394) of individuals reported PTSS 6 months following MVC. Regularized linear regression was the top performing learning method. The top 30 factors together showed good reliability in predicting PTSS in the external sample (Area under the curve = 0.79 ± 0.002). Top predictors included acute pain severity, recovery expectations, socioeconomic status, self-reported race, and psychological symptoms.

CONCLUSIONS

These analyses add to a growing literature indicating that influential predictors of PTSS can be identified and risk for future PTSS estimated from characteristics easily available/assessable at the time of ED presentation following TSE.

Clinical Hypnosis for Procedural Pain and Distress in Children: A Scoping Review

OBJECTIVE

Pain and distress are common in children undergoing medical procedures, exposing them to acute and chronic biopsychosocial impairments if inadequately treated. Clinical hypnosis has emerged as a potentially beneficial treatment for children's procedural pain and distress due to evidence of effectiveness and potential superiority to other psychological interventions. However, systematic reviews of clinical hypnosis for children's procedural pain and distress have been predominantly conducted in children undergoing oncology and needle procedures and are lacking in broader pediatric contexts. This scoping review maps the evidence of clinical hypnosis for children's procedural pain and distress across broad pediatric contexts while highlighting knowledge gaps and areas requiring further investigation.

METHODS

Published databases (PubMed, Cochrane Library, PsycINFO, Embase, CINAHL, Scopus, and Web of Science) and grey literature were searched in addition to hand-searching reference lists and key journals (up to May 2022). Two independent reviewers screened the titles and abstracts of search results followed by a full-text review against eligibility criteria. Articles were included if they involved a clinical hypnosis intervention comprising an induction followed by therapeutic suggestions for pain and distress in children undergoing medical procedures. This review followed the Arksey and O'Malley (2005) methodology and incorporated additional scoping review recommendations by the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 38 eligible studies involving 2,205 children were included after 4,775 articles were screened. Research on clinical hypnosis for children's procedural pain and distress was marked by a lack of fidelity measures and qualitative data as well as by inadequate intervention reporting and high attrition rates. Evidence regarding the safety of clinical hypnosis, pain unpleasantness outcomes, factors influencing outcomes, as well as barriers and facilitators to implementing hypnosis and study procedures was also lacking. Clinical hypnosis has potential benefits for children's procedural pain and distress based on evidence of superiority to control conditions and nonpharmacological interventions (e.g., distraction, acupressure) with moderate to large effect sizes as reported in 76% of studies. However, heterogeneous interventions, contexts, study designs, and populations were identified, and the certainty of the evidence was not evaluated.

CONCLUSIONS

The review suggests potential benefits of clinical hypnosis for children's procedural pain and distress and thus provides a precursor for further systematic reviews and trials investigating the effectiveness of clinical hypnosis. The review also indicates the need to further explore the feasibility, acceptability, implementation, and safety of clinical hypnosis in children undergoing painful procedures. Based on the review, researchers implementing clinical hypnosis should adequately report interventions or use treatment manuals, follow recommended research guidelines, and assess the fidelity of intervention delivery to promote replicating and comparing interventions. The review also highlights common methodological shortcomings of published trials to avoid, such as the lack of implementation frameworks, small sample sizes, inadequate reporting of standard care or control conditions, and limited evidence on pain unpleasantness outcomes.

The Differential Influence of PZM21, A Nonrewarding μ-opioid Receptor Agonist With G Protein Bias, on Behavioural Despair and Fear Response in Mice

A growing body of evidence points out the involvement of the µ-opioid receptors in the modulation of stress-related behaviour. It has been suggested that µ-opioid receptor agonists may attenuate behavioural despair following animals' exposure to an acute, inescapable stressor. Moreover, morphine was shown to ameliorate fear memories caused by a traumatic experience. As typical µ-opioid receptor agonists entail a risk of serious side effects and addiction, novel, possibly safer and less addictive agonists of this receptor are currently under investigation. One of them, PZM21, preferentially acting via the G protein signalling pathway, was previously shown to be analgesic, but less addictive than morphine. Here, we aimed to further test this ligand in stress-related behavioural paradigms in mice. The study has shown that, unlike morphine, PZM21 does not decrease immobility in the forced swimming and tail suspension tests. On the other hand, we observed that both mice treated with PZM21 and those receiving morphine presented a slight attenuation of freezing across the consecutive fear memory retrievals in the fear conditioning test. Therefore, our study implies that at the range of tested doses, PZM21, a nonrewarding representative of G protein-biased µ-opioid receptor agonists, may interfere with fear memory consolidation while having no beneficial effects on behavioural despair in mice.

Pre-hospital analgesia in pediatric trauma and critically ill patients: An analysis of a German air rescue service

BACKGROUND

Pain management in the pre-hospital setting remains a particular challenge for paramedics and emergency physicians, especially in children. This study evaluates the pre-hospital use and effect of analgesics in children with trauma or pain due to other reasons.

METHODS

This study is a retrospective analysis of the database of a German air rescue service and was conducted over a period of 9 years (2012-2020) to assess pain in general and whether patients with trauma pain due to other reasons received treatment with analgesics. We included all patients in the registry under the age of 16 years. Patients with a Glasgow Coma Scale of 3 at hospital admission and incomplete records were excluded. The intensity of pain was determined by the emergency physician on scene at arrival and hospital admission in a ten-point rating scale (0 = no pain). Effective pain reduction was analyzed.

RESULTS

Out of 227,458 cases, a total of 22,025 emergency cases involved pediatric patients aged 0-16 years. 20,405 cases were included in the study. 12,000 (58.8%) children had suffered a trauma, 8108 (39.7%) had pain due to other reasons and 297 (1.5%) had both. In total, 4,608 (38.4%) of the children with trauma were assessed having a numerical rating scale (NRS) > 4 at EMS arrival. These patients received mainly ketamine (34.5%) and the opioids fentanyl (38.7%) and piritramide (19.1%). The value on the NRS was significantly lower at admission to hospital (mean 1.9) compared with the EMS arrival (mean 6.9). In 4.9% the NRS at hospital admission was still > 4. 282 patients within the non-trauma group had a pre-hospital NRS of > 4. The pain therapy consisted of opioids (35.8%) and ketamine (2.8%). 28.4% patients in the non-trauma group received no pain medication. In 16.0% the NRS at hospital admission was still > 4.

CONCLUSIONS

German emergency physicians achieved a sufficient pain therapy in pediatric patients with a NRS > 4 after trauma. In case of non-trauma, the pain management by the emergency physicians is restrained and less successful. The most common analgesic medications administered were ketamine and fentanyl, followed by piritramide.

TRIAL REGISTRATION

The study has been retrospectively registered at DRKS (DRKS00026222).

Postoperative opioid administration and post-traumatic stress symptoms in preschool children after cardiac surgery

PURPOSE

The purpose of this study was to explore relationships between postoperative opioid administration and posttraumatic stress symptoms (PTSS) in preschool-aged children surviving cardiac surgery.

DESIGN AND METHODS

This was a cross-sectional, descriptive study using survey administration and medical chart review. Primary caregivers of children aged three to six years who underwent cardiac surgery at our institution between 2018 and 2020 were invited to participate. Opioid administration was calculated according to morphine milligram equivalents and indexed to the child's body weight. Caregivers completed the Young Child Posttraumatic Stress Disorder Checklist to explore child PTSS. We used correlational methods to assess the strength and direction of relationships between postoperative opioid administration and child PTSS.

RESULTS

We did not find a statistically significant relationship between total postoperative opioid administration and child PTSS. When analyzing individual opioid agents, morphine did show a significant inverse relationship to YCPC scores (r_s = -.57, p = .017) in children with single ventricle physiology.

CONCLUSIONS

Total postoperative opioid administration was not statistically significantly related to child PTSS in our sample. Differing patterns of association were noted among children with single- versus bi-ventricular physiology. Postoperative morphine administration was favorably associated with PTSS in children with single-ventricle physiology.

PRACTICE IMPLICATIONS

Nurses caring for preschool children who undergo cardiac surgery should anticipate the potential development of PTSS in their patients. Studies using larger sample sizes and longitudinal design are needed to replicate the significant relationship between morphine administration and PTSS in preschoolers with single-ventricle physiology.

Propranolol versus Other Selected Drugs in the Treatment of Various Types of Anxiety or Stress, with Particular Reference to Stage Fright and Post-Traumatic Stress Disorder

Propranolol, a non-cardioselective β1,2 blocker, is most commonly recognised for its application in the therapy of various cardiovascular conditions, such as hypertension, coronary artery disease, and tachyarrhythmias. However, due to its ability to cross the blood-brain barrier and affinity towards multiple macromolecules, not only adrenoreceptors, it has also found application in other fields. For example, it is one of the very few medications successfully applied in the treatment of stage fright. This review focuses on the application of propranolol in the treatment of various types of anxiety and stress, with particular reference to stage fright and post-traumatic stress disorder (PTSD). Both mechanisms of action as well as comparison with other therapies are presented. As those indications for propranolol are, in most countries, considered off-label, this review aims to gather information that can be useful while making a decision about the choice of propranolol as a drug in the treatment of those mental conditions.

Effects of acute pain medications on posttraumatic stress symptoms in early aftermath of trauma

Posttraumatic stress symptoms (PTSS) develop as sequelae from traumatic injuries. Limited studies suggest that using opioids to reduce acute pain immediately after trauma may also reduce subsequent PTSS, but other pain medications rarely have been examined for preventing acute PTSS. The current study examined the effects of commonly used pain medications, opioid and nonsteroidal anti-inflammatory drugs (NSAIDs), on PTSS after acute traumatic injuries. Participants ( n = 71) were categorized into opioid or NSAID group according to their medical records and self-reported medication use. Their PTSS were assessed using posttraumatic stress disorder checklist twice within 2 weeks after trauma. Participants' pain levels reduced from pretreatment to follow-up in both groups, F (1, 55) = 6.696, P = 0.012, partial η 2 = 0.109. Interestingly, a significant interaction between time and medication group on PTSS reached statistical significance, F (1, 69) = 6.014, P = 0.017, partial η 2 = 0.080. Follow-up analyses revealed that this interaction was driven by a significant PTSS reduction only in opioid but not in NSAID group. These findings suggested that pain reduction alone is not sufficient to reduce acute PTSS in the NSAID group, highlighting the need to continue further investigations into the mechanisms by which opioids reduce PTSS in the early posttrauma period.

Acute pain management in the trauma patient population: are we doing enough? A prospective observational study

Purpose

There is a strong correlation between trauma and pain. Pain increases the rate of depression, posttraumatic stress disorder, and even mortality in trauma patients.

Methods

This institution-based, provider-blinded and patient-blinded, observational study was conducted among trauma patients treated at kur Anbessa Specialized Hospital. Over the course of 3 months, this study included patients who had no prior pain management at other hospitals before presentation, and who presented within 24 hours of the traumatic event.

Results

Of the 74 patients evaluated, none of the patients had their pain level scored. The researcher-provided pain scale showed a severe subjective pain score for 79.7% of the patients and a severe functional activity score for 59.5% of the patients. Analgesia was provided at an average of 55.4 minutes after presentation and all patients received either diclofenac or tramadol. Satisfactory pain reduction after analgesia was 28.8% for patients initially complaining of severe pain, 54.6% for moderate pain, and 66.7% for mild pain, with the difference being statistically significant (P<0.05). Forty percent of patients discharged home received no analgesia after the first dose provided upon presentation.

Conclusions

Pain scoring was nonexistent during the course of the study. The poor utilization rate of analgesia combination and opioids led to unsatisfactory pain outcomes in patients evaluated and followed for 24 hours after presentation.

Five-year incidence of substance use and mental health diagnoses following exposure to opioids or opioids with benzodiazepines during an emergency department encounter for traumatic injury

BACKGROUND

Benzodiazepines and opioids are used alone or in conjunction in certain care settings, but each have the potential for misuse.

OBJECTIVE

This longitudinal observational study evaluated substance use and mental health outcomes associated with providing opioids with or without benzodiazepine to treat traumatic injury in the emergency department (ED) setting.

METHODS

We analyzed a limited dataset obtained through the IBM Watson Health Explorys. Matched cohorts were defined for: 1) patients treated with opioids during the ED encounter (ED-Opioid) vs. neither opioid or benzodiazepine treatment (No medication) (n = 5372); 2) patients treated with opioids and benzodiazepines during the ED encounter (ED-Opioid+Benzodiazepines) vs. No Medication (n = 2454); and 3) ED-Opioid+Benzodiazepines vs. ED-Opioid (n = 2454). Patients consisted of adults with an emergency department encounter in the MetroHealth System (Cleveland, Ohio) with a chief complaint of traumatic injury and medical records for five years following the encounter. Control patients for each cohort were matched to the exposure patients on demographics, body mass index, and residential zip code median income. Outcomes were five-year incidence rates for alcohol, substance use, depression, and anxiety-related diagnoses.

RESULTS

Our results indicate that, although receiving opioids during the ED visit predicted a relatively lower likelihood of subsequent substance use and mental health diagnoses, the brief co-use of benzodiazepines was strongly associated with poorer outcomes.

CONCLUSIONS

Even brief exposure to co-prescribed opioids and benzodiazepines during emergency traumatic injury care may be associated with negative substance use and mental health consequences in the years following the event.

Association of Pre-procedural Anxiety with Procedure-related Pain During Outpatient Pediatric Burn Care: A Pilot Study

The relationship between preprocedural anxiety and pain is not clear but has the potential to change the way pediatric patients need to be cared for prior to burn procedures. Using results from our recent randomized clinical trial among outpatient burn patients (n=90) age 6-17 years, the objective of this subsequent analysis was to assess whether preprocedural anxiety was associated with self-reported and researcher observed pain scores. Anxiety before the dressing change was assessed using an abbreviated State-Trait Anxiety Inventory for Children (range 6-21) and reported with 95% confidence intervals (CI). Self-reported pain was reported using a Visual Analog Scale (range 0-100) and observed pain was assessed using the Face, Legs, Activity, Cry, and Consolability-revised scale. Over half of patients (58.9%) reported mild anxiety (score <12) and about 5% of patients reported severe anxiety (score >16). Younger children (6-8 years) reported higher anxiety scores than older children (15-17 years), but the difference did not achieve statistical significance (mean=12.7, 95% CI: 11.5-13.9, p=0.09). Nonparametric spearman correlation indicated that anxiety score was significantly correlated with observed pain (p=0.01) and self-reported overall pain neared statistical significance (p=0.06). In the final logistic regression of reporting moderate-to-severe pain (pain score >30), the association between anxiety scores and self-reported overall moderate-to-severe pain was statistically significant (p=0.03) when adjusting for race, healing degree, and pain medication use within 6 hours prior to burn dressing care. This pilot study provides preliminary data showing that anxiety before outpatient pediatric burn dressing changes is significantly associated with self-reported overall moderate-to-severe pain.

Improving ambulance care for children suffering acute pain: a qualitative interview study

Background

Pain is a highly complex sensory and emotional experience. When a child suffers acute pain through illness or injury, they are often transported to hospital by ambulance. Pre-hospital pain management in children is poor, with 61% of children receiving suboptimal pain management. Consequences of poor pain management include the risk of developing post-traumatic stress disorder and altered pain perception. We aimed to identify clinicians’ perceptions of barriers, facilitators and potential improvements for the management of pre-hospital acute pain in children.

Methods

Qualitative face to face semi-structured recorded interviews were performed in one large UK ambulance service. Audio files were transcribed verbatim with thematic analysis used to generate themes. NVivo 12 was used to support data analysis. Findings were combined with existing evidence to generate a driver diagram.

Results

Twelve ambulance clinicians participated, including 9 registered paramedics and 3 emergency medical technicians. Median (IQR) age was 43.50 (41.50, 45.75) years, 58% were male, median (IQR) experience was 12 (4.25, 15.50) years and 58% were parents. Several themes relating to barriers and facilitators were identified, including physical, emotional, social, organisational, environmental, management, knowledge and experience. Improvement themes were identified relating to management, organisation and education. These data were combined to create a driver diagram; the three primary drivers were 1) explore methods to increase rates of analgesic administration, including utilising intranasal or inhaled routes; 2) reduce fear and anxiety in children, by using child friendly uniform, additional non-pharmacological techniques and more public interaction and 3) reduce fear and anxiety in clinicians, by enhancing training and optimising crew mix.

Conclusions

The quality of care that children receive for acute pain in the ambulance service may be improved by increasing rates of analgesic administration and reducing the fear and anxiety experienced by children and clinicians. Future research involving children and parents would be useful to determine the most important outcome measures and facilitate intervention development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00648-y.

Traumatic Stress-Induced Vulnerability to Addiction: Critical Role of the Dynorphin/Kappa Opioid Receptor System

Substance use disorders (SUD) may emerge from an individual’s attempt to limit negative affective states and symptoms linked to stress. Indeed, SUD is highly comorbid with chronic stress, traumatic stress, or post-traumatic stress disorder (PTSD), and treatments approved for each pathology individually often failed to have a therapeutic efficiency in such comorbid patients. The kappa-opioid receptor (KOR) and its endogenous ligand dynorphin (DYN), seem to play a key role in the occurrence of this comorbidity. The DYN/KOR function is increased either in traumatic stress or during drug use, dependence acquisition and DYN is released during stress. The behavioural effects of stress related to the DYN/KOR system include anxiety, dissociative and depressive symptoms, as well as increased conditioned fear response. Furthermore, the DYN/KOR system is implicated in negative reinforcement after the euphoric effects of a drug of abuse ends. During chronic drug consumption DYN/KOR functions increase and facilitate tolerance and dependence. The drug-seeking behaviour induced by KOR activation can be retrieved either during the development of an addictive behaviour, or during relapse after withdrawal. DYN is known to be one of the most powerful negative modulators of dopamine signalling, notably in brain structures implicated in both reward and fear circuitries. KOR are also acting as inhibitory heteroreceptors on serotonin neurons. Moreover, the DYN/KOR system cross-regulate with corticotropin-releasing factor in the brain. The sexual dimorphism of the DYN/KOR system could be the cause of the gender differences observed in patients with SUD or/and traumatic stress-related pathologies. This review underlies experimental and clinical results emphasizing the DYN/KOR system as common mechanisms shared by SUD or/and traumatic stress-related pathologies, and suggests KOR antagonist as a new pharmacological strategy to treat this comorbidity.

Early Interventions to Prevent Post-Traumatic Stress Disorder in Youth after Exposure to a Potentially Traumatic Event: A Scoping Review

The worldwide occurrence of potentially traumatic events (PTEs) in the life of children is highly frequent. We aimed to identify studies on early mental health interventions implemented within three months of the child/adolescent's exposure to a PTE, with the aim of reducing acute post-traumatic symptoms, decreasing long term PTSD, and improving the child's adjustment after a PTE exposure. The search was performed in PubMed and EMBASE databases resulting in twenty-seven articles meeting our inclusion criteria. Most non-pharmacological interventions evaluated had in common two complementary components: psychoeducation content for both children and parents normalizing early post-traumatic responses while identifying post-traumatic symptoms; and coping strategies to deal with post-traumatic symptoms. Most of these interventions studied yielded positive results on outcomes with a decrease in post-traumatic, anxiety, and depressive symptoms. However, negative results were noted when traumatic events were still ongoing (war, political violence) as well as when there was no or little parental involvement. This study informs areas for future PTSD prevention research and raises awareness of the importance of psychoeducation and coping skills building in both youth and their parents in the aftermath of a traumatic event, to strengthen family support and prevent the occurrence of enduring post-traumatic symptoms.

Hypnotherapy for Procedural Pain and Distress in Children: A Scoping Review Protocol

OBJECTIVE

Inadequately treated pain and distress elicited by medical procedures can put children at higher risk of acute and chronic biopsychosocial sequelae. Children can benefit from hypnotherapy, a psychologically tailored intervention, as an adjunct to pharmacological agents to address the multiple components of pain and distress. Despite providing evidence on the effectiveness and potential superiority of hypnotherapy to other psychological interventions, research on hypnotherapy for pediatric procedural pain and distress has been predominantly limited to oncology and needle procedures. Plus, there is a lack of reporting of intervention manuals, factors influencing hypnotic responding, pain unpleasantness outcomes, theoretical frameworks, adverse events, as well as barriers and facilitators to the feasibility of delivering the intervention and study procedures. The proposed review aims to map the range and nature of the evidence on hypnotherapy for procedural pain and distress in children to identify gaps in literature and areas requiring further investigation.

METHODS

This review will follow the Arksey and O'Malley (2005) methodology and incorporate additional scoping review recommendations by the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses. Relevant studies will be identified through searching published literature databases (PubMed, Cochrane Library, PsycINFO, Embase, CINAHL, Scopus and Web of Science) and grey literature in addition to hand-searching of reference lists and key journals. Two authors will independently screen titles and abstracts of search results followed by full-texts review against eligibility criteria.

CONCLUSION

Findings are anticipated to guide future research and inform the development of tailored hypnotic interventions in children.

Neuraxial anesthesia and pain control for pediatric burn patients receiving excision and split-thickness skin grafts-A retrospective case series

BACKGROUND

Postoperative pain management in pediatric burn patients requiring excision and split-thickness skin grafts remains largely under-studied. ICU care is often necessary due to the level of sedation and amount of opioids required to achieve adequate pain control.

AIMS

Our case series aimed to describe a pain management strategy using neuraxial anesthesia intraoperatively. Primary outcomes include pain scores, postoperative opioid consumption, and adverse events.

METHODS

A retrospective chart review was performed on a total of 61 patients who received intraoperative neuraxial anesthesia for split-thickness skin grafting between January 1st, 2017 and June 1st, 2018. Patient demographics, operating room data, and subsequent hospital course was extracted from their electronic medical record and plotted using R Studio statistical software.

RESULTS

The overwhelming majority of patients received single-shot spinals with both local anesthetic and either morphine or hydromorphone. Average pain scores were 1 out of 10 with standard deviation of 1.6 in the immediate postoperative period and decreased over the next 72 h. Oral morphine equivalents consumed did not exceed 0.61 ME/kg/day. The most common adverse reaction was pruritus.

CONCLUSIONS

Spinal anesthesia was most commonly used for split-thickness skin grafting in the pediatric burn population and provides excellent analgesia for patients' immediate postoperative course, including their initial dressing changes, with minimal risk for complications. Pain was well-controlled in all subgroups indicating that this strategy can be used flexibly in a variety of pediatric burn patients.

The predictors, barriers and facilitators to effective management of acute pain in children by emergency medical services: A systematic mixed studies review

We aimed to identify predictors, barriers and facilitators to effective pre-hospital pain management in children. A segregated systematic mixed studies review was performed. We searched from inception to 30-June-2020: MEDLINE, CINAHL Complete, PsycINFO, EMBASE, Web of Science Core Collection and Scopus. Empirical quantitative, qualitative and multi-method studies of children under 18 years, their relatives or emergency medical service staff were eligible. Two authors independently performed screening and selection, quality assessment, data extraction and quantitative synthesis. Three authors performed thematic synthesis. Grading of Recommendations Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research were used to determine the confidence in cumulative evidence. From 4030 articles screened, 78 were selected for full text review, with eight quantitative and five qualitative studies included. Substantial heterogeneity precluded meta-analysis. Predictors of effective pain management included: 'child sex (male)', 'child age (younger)', 'type of pain (traumatic)' and 'analgesic administration'. Barriers and facilitators included internal (fear, clinical experience, education and training) and external (relatives and colleagues) influences on the clinician along with child factors (child's experience of event, pain assessment and management). Confidence in the cumulative evidence was deemed low. Efforts to facilitate analgesic administration should take priority, perhaps utilising the intranasal route. Further research is recommended to explore the experience of the child. Registration: PROSPERO CRD42017058960.

Ambulance clinician perspectives of disparity in prehospital child pain management: A mixed methods study

BACKGROUND

When children suffer acute pain, the ambulance service is often involved to provide initial assessment, treatment, and transport. Several predictors of effective pain management have been identified, including children who are younger (0-5 years), administered analgesics, and living in homes from more affluent areas.

OBJECTIVE

To explain previously identified predictors of effective prehospital pain management in children.

DESIGN

Mixed methods sequential explanatory study.

SETTING AND PARTICIPANTS

East Midlands Ambulance Service National Health Service Trust paramedics and emergency medical technicians (EMTs) participated in face-to-face semi-structured interviews. These were audio recorded, transcribed verbatim, and coded using thematic analysis. Meta-inferences were generated and illustrated within a joint display.

RESULTS

Twelve clinicians (9 paramedics and 3 EMTs) were interviewed. Median (interquartile range) age was 43.5 years (41.5, 45.75), 58% were male (n = 7) and 58% were parents (n = 7). Possible explanations were provided for all predictors. Younger children were perceived to express more emotion, were easier to distract, and lived more in the moment than their older counterparts, which explained why younger children were more likely to achieve effective pain management. Analgesics were perceived to have a psychosocial benefit in addition to the pharmacological action. Ambulance clinicians felt that children living in more affluent areas were more likely to achieve effective pain management because the kempt environment facilitated assessment and management and clinicians spent more time on scene; this allowed more time for analgesics to take effect. Participants perceived paramedics to be more confident, and it was found that paramedics were older, more experienced, had a greater scope of practice, and spent more time on scene than EMTs.

CONCLUSION

Prehospital pain management in children could be improved by facilitating and prioritizing analgesic administration and by ambulance services ensuring a paramedic, or highly trained clinician, is present on each vehicle, necessitating long-term commitment to staff development.

A critical review of mechanisms of adaptation to trauma: Implications for early interventions for posttraumatic stress disorder

Although many attempts have been made to limit development of posttraumatic stress disorder (PTSD) by early intervention after trauma exposure, these attempts have achieved only modest success. This review critiques the biological and cognitive strategies used for early intervention and outlines the extent to which they have prevented PTSD. The major predictors of PTSD are reviewed, with an emphasis on potential mechanisms that may underpin the transition from acute stress reaction to development of PTSD. This review highlights that there is a wide range of biological and cognitive factors that have been shown to predict PTSD. Despite this, the major attempts at early intervention have focused on strategies that attempt to augment extinction processes or alter appraisals in the acute period. The documented predictors of PTSD indicate that a broader range of potential strategies could be explored to limit PTSD. The evidence that people follow different trajectories of stress response following trauma and there is a wide array of acute predictors of PTSD indicates that a flexible and tailored approach needs to be investigated to evaluate more effective early intervention strategies.

Ventral Tegmental Area Dysfunction and Disruption of Dopaminergic Homeostasis: Implications for Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a debilitating psychiatric condition characterized by intrusive recollections of the traumatic event, avoidance behaviors, hyper-arousal to event-related cues, cognitive disruption, and mood dysregulation. Accumulating preclinical and clinical evidence implicates dysfunction of the ventral tegmental area (VTA) dopaminergic system in PTSD pathogenesis. This article reviews recent advances in our knowledge of the relationship between dopaminergic dyshomeostasis and PTSD, including the contributions of specific dopaminergic gene variants to disease susceptibility, alterations in VTA dopamine neuron activity, dysregulation of dopaminergic transmission, and potential pharmacological and psychological interventions for PTSD targeting the dopaminergic system. An in-depth understanding of PTSD etiology is crucial for the development of innovative risk assessment, diagnostic, and treatment strategies following traumatic events.

Habenula kisspeptin retrieves morphine impaired fear memory in zebrafish

The habenula is an evolutionarily conserved brain structure, which has recently been implicated in fear memory. In the zebrafish, kisspeptin (Kiss1) is predominantly expressed in the habenula, which has been implicated as a modulator of fear response. Hence, in the present study, we questioned whether Kiss1 has a role in fear memory and morphine-induced fear memory impairment using an odorant cue (alarm substances, AS)-induced fear avoidance paradigm in adult zebrafish, whereby the fear-conditioned memory can be assessed by a change of basal place preference (= avoidance) of fish due to AS-induced fear experience. Subsequently, to examine the possible role of Kiss1 neurons-serotonergic pathway, kiss1 mRNA and serotonin levels were measured. AS exposure triggered fear episodes and fear-conditioned place avoidance. Morphine treatment followed by AS exposure, significantly impaired fear memory with increased time-spent in AS-paired compartment. However, fish administered with Kiss1 (10^–21 mol/fish) after morphine treatment had significantly lower kiss1 mRNA levels but retained fear memory. In addition, the total brain serotonin levels were significantly increased in AS- and Kiss1-treated groups as compared to control and morphine treated group. These results suggest that habenular Kiss1 might be involved in consolidation or retrieval of fear memory through the serotonin system.

Feasibility and Clinical Utility of the Finnish Version of the FLACC Pain Scale in PICU

PURPOSE

To describe the feasibility and clinical utility of the Finnish FLACC scale when assessing children's pain in a Pediatric Intensive Care Unit (PICU).

DESIGN AND METHODS

A non-experimental, descriptive cross-sectional study design was used to describe the feasibility and clinical utility in a Finnish PICU between May and August 2018. The nurses were asked to complete a data collection questionnaire about the feasibility and clinical utility of the Finnish FLACC every time they used the scale to assess pain in children. In total, the data consisted of 157 pain assessments cases. Quantitative data were analyzed statistically and responses to open-ended questions were analyzed using content analysis.

RESULTS

In most cases, the nurses agreed that the Finnish FLACC scale was clearly structured (97%), easy to use (98%), helpful in assessing pain intensity (77%), and useful when reassessing pain after interventions (67%). Nurses found the scale more useable for children over one year old than for younger children. When assessing cry and consolability, pain was easier to score if the child was not intubated.

CONCLUSIONS

The Finnish FLACC scale exhibits adequate feasibility and clinical utility when assessing pain in children in a PICU. However, more information is needed about its use during painful short-term procedures and with children under one year old.

PRACTICE IMPLICATIONS

The Finnish FLACC scale is a helpful tool for nurses when assessing children's pain in a PICU. However, the Finnish version of the modified FLACC is needed for use with intubated children in the future.

Posttraumatic Stress in Children After Injury: The Role of Acute Pain and Opioid Medication Use

OBJECTIVES

After injury, many children experience posttraumatic stress symptoms (PTSS) that negatively impact recovery. Acute pain and PTSS share neurobiological pathways, and acute dosage of morphine has been linked to reduced PTSS in naturalistic studies. However, the complex interactions between pain, morphine and other opioid use, and PTSS have yet to be investigated in robust pediatric samples.This prospective, longitudinal study examined relationships between acute pain, opioid medications, and PTSS after pediatric injury.

METHODS

Ninety-six children aged 8 to 13 years (mean = 10.60, SD = 1.71), hospitalized for unintentional injury, completed assessments at baseline (T1) and 12 weeks (T2) later. Pain ratings and opioid administration data were obtained via chart review.

RESULTS

Structural equation modeling revealed that worst pain endorsed during hospitalization was positively associated with concurrent and later PTSS when controlling for evidence-based risk factors (ie, age, sex, prior trauma history, traumatic appraisals of injury event, heart rate). Neither opioid medications overall nor morphine specifically (milligram/kilogram/day) administered during hospitalization mediated the relationship between pain and T2 PTSS.

CONCLUSIONS

Pain during hospitalization may increase susceptibility for persistent PTSS above and beyond the influence of other empirical risk factors. Findings suggest that pain assessment may be a useful addition to pediatric PTSS screening tools and highlight the need for additional research on pharmacological secondary prevention approaches. Given that inadequate pain control and persistent PTSS each hinder recovery and long-term functioning, better understanding of interactions between acute pain and PTSS after injury is essential for improving screening, prevention, and early intervention efforts.

Lowered endogenous mu-opioid receptor availability in subclinical depression and anxiety

Major depressive disorder is associated with lowered mood, anxiety, anhedonia, sleep problems, and cognitive impairments. Many of these functions are regulated by μ-opioid receptor (MOR) system. Preclinical, in vivo, and post-mortem studies have however yielded inconclusive results regarding the role of the MOR in depression and anxiety. Moreover, it is not known whether alterations in MOR are already present in subclinical depression and anxiety. In a large-scale retrospective cross-sectional study we pooled data from 135 (113 males and 22 females) healthy subjects whose brain's MOR availability was measured with positron emission tomography (PET) using an agonist radioligand [11C]carfentanil that has high affinity for MORs. Depressive and anxious symptomology was addressed with BDI-II and STAI-X questionnaires, respectively. Both anxiety and depression scores in the subclinical range were negatively associated with MOR availability in cortical and subcortical areas, notably in amygdala, hippocampus, ventral striatum, and orbitofrontal and cingulate cortices. We conclude that dysregulated MOR availability is involved in altered mood and pathophysiology of depression and anxiety disorders.

A web-based educational intervention to implement trauma-informed care in a paediatric healthcare setting: protocol for a feasibility study using pre-post mixed methods design

Background

Adoption of responsive trauma-informed practices by staff in hospital-based paediatric care may help mitigate downstream costs associated with treatment delivery due to reduced pain and distress for children and care providers, improved health-related quality of life and increased satisfaction with care. A web-based education intervention (termed Responsive CARE) was developed to build self-efficacy of staff in a paediatric medical setting. This protocol paper describes a feasibility study (including preliminary effectiveness) of the implementation of Responsive CARE in a tertiary, outpatient burn clinical setting.

Methods

A pre-post, mixed methods design will be employed. Children and caregivers attending hospital for change of burn wound dressings or burn scar management during the 3-month control or 3-month intervention period will be eligible, with follow-up to 6-months post-baseline. All children and caregiver/s will receive “standard care” including burn interventions focused on wound healing, scar management, itch management (both pharmacological and non-pharmacological), counselling, age-appropriate procedural support and burn rehabilitation. Health professional participants will be those involved in the management of children with burns during the study period or their senior managers. Health professional participants who attend a weekly educational clinical meeting will be invited to complete the intervention during a 1-month timeframe between the control and intervention period (or upon their commencement in burn outpatients during the intervention period) using an individualised log-in process. A purposive sample of caregivers and health professionals will be sought for participation in semi-structured interviews. Qualitative data will be analysed using Framework analysis. Feasibility will be evaluated via interviews, digital records of intervention usage and technical assistance logs. The primary outcome measures of effectiveness (pain, itch and distress) will be measured using self-report or behavioural observation. Quantitative data will primarily be analysed descriptively and using generalised linear models.

Discussion

This study will provide insights into factors that impact upon the feasibility of a web-based trauma-informed care education intervention in a clinical practice setting. This knowledge may support other education approaches within healthcare settings related to improving and supporting patients to reduce the risk of healthcare interactions that result in paediatric medical traumatic stress.

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

BACKGROUND

Intensive care (ICU) patients' burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity.

AIMS

To understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients.

METHODS

Consecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model.

RESULTS

Overall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged. Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant.

CONCLUSIONS

Effective pain assessment, management and advocacy are assisted by evidence-based assessment practices.

Buprenorphine: prospective novel therapy for depression and PTSD

BACKGROUND

Depression and post-traumatic stress disorder (PTSD) are leading causes of disability and loss of life by suicide. Currently, there are less than satisfactory medical solutions to treat these mental disorders. Here, we explore recent preclinical and clinical studies demonstrating the potential of using buprenorphine to treat major depressive disorder, treatment-resistant depression, and PTSD.

METHOD

Bibliographic databases were searched to include preclinical and clinical studies demonstrating the therapeutic potential of buprenorphine and the involvement of the kappa opioid receptor (KOR) in mediating these effects.

RESULTS

Original clinical studies examining the effectiveness of buprenorphine to treat depression were mixed. The majority of participants in the PTSD studies were males and suffer from chronic pain and/or substance use disorders. Nonetheless, these recent studies and analyses established proof of concept warranting farther investigations. Additionally, KOR likely mediates the antidepressant and some of the anxiolytic effects of buprenorphine. Still, it appears that the full spectrum of buprenorphine's beneficial effects might be due to activity at other opioid receptors as well.

CONCLUSIONS

Pharmaceuticals' abilities to treat medical conditions directly relates to their ability to act upon the endogenous biological systems related to the conditions. Thus, these recent findings are likely a reflection of the central role that the endogenous opioid system has in these mental illnesses. Further studies are necessary to study the involvement of endogenous opioid systems, and specifically KOR, in mediating buprenorphine's beneficial effects and the ability to treat these medical conditions while minimizing risks for misuse and diversion.

Post-Cardiotomy Parasternal Nerve Block with Bupivacaine may be Associated with Reduced Post-Operative Opioid Use in Children: A Retrospective Cohort Study

Postoperative pain treatment affects immediate and long-term outcomes in children undergoing cardiac surgery. Opioids, as part of multimodal analgesia, are effective in treating pain, however, they can be disadvantageous due to adverse side effects. Therefore, we assessed whether the local anesthetic bupivacaine as a parasternal nerve block in children post-cardiac surgery is an effective adjunct to pain management. This was a retrospective cohort study of all patients who underwent cardiothoracic surgery via median sternotomy at a large children’s hospital between November 2011 and February 2014 with and without bupivacaine following the introduction of perioperative bupivacaine in late 2012 on a single unit. 62 out of 148 patients (age 3–17 years) who received bupivacaine demonstrated decreased postoperative opioid use. Within one day of surgery, patients who received bupivacaine required, on average, 0.57 mg/kg (95% CI, 0.46 to 0.68) of total morphine equivalent compared to 0.93 mg/kg (95% CI, 0.80 to 1.06) for patients who did not receive bupivacaine. This difference was statistically significant after adjusting for potential confounders (p-value = 0.002). Length of stay and intubation were shorter on average among patients who received bupivacaine, but these differences were not statistically significant after adjusting for potential confounders. The study results seem to suggest that the perioperative administration of bupivacaine may reduce opioid usage among children post-cardiotomy.

A novel theory on the predictive value of variation in the β-endorphin system on the risk and severity of PTSD

Despite growing interest in genetic and psychosocial indicators of heightened susceptibility to posttraumatic stress disorder (PTSD), a predictive model, which explains why some individuals develop PTSD in response to life-threatening traumatic events, while others, when faced with the same or similar experiences, do not, has thus far remained out of reach. In this paper, we review the literature on gene-environment interactions in β-endorphin system functioning with regard to PTSD and suggest that variation, both genetic and with regard to environmental stimuli, in systems which, like the β-endorphin system, distort human perception of life-threatening traumatic experiences may account for some of the variance in resilience to the disorder. Given the role of β-endorphin in both social connections and physical exercise, this becomes especially relevant with regard to military selection, training, and leadership processes.

Pain management in trauma patients affected by the opioid epidemic: A narrative review

Acute and chronic pain in trauma patients remains a challenging entity, particularly in the setting of the escalating opioid epidemic. It has been reported that chronic opioid use increases the likelihood of hospital admissions as a result of traumatic injuries. Furthermore, patients admitted with traumatic injuries have a greater than average risk of developing opioid use disorder after discharge. Practitioners providing care to these patients will encounter the issue of balancing analgesic goals and acute opioid withdrawal with the challenge of reducing postdischarge persistent opioid use. Additionally, the practitioner is faced with the worrisome prospect that inadequate treatment of acute pain may lead to the development of chronic pain and overtreatment may result in opioid dependence. It is therefore imperative to understand and execute alternative nonopioid strategies to maximize the benefits and reduce the risks of analgesic regimens in this patient population. This narrative review will analyze the current literature on pain management in trauma patients and highlight the application of the multimodal approach in potentially reducing the risks of both short- and long-term opioid use. LEVEL OF EVIDENCE: Narrative review, moderate to High.

Predictors of effective management of acute pain in children within a UK ambulance service: A cross-sectional study

OBJECTIVE

We aimed to identify predictors of effective management of acute pain in children in the pre-hospital setting.

METHODS

A retrospective cross-sectional study using electronic clinical records from one large UK ambulance service during 01-Oct-2017 to 30-Sep-2018 was performed using multivariable logistic regression. We included all children <18 years suffering acute pain. Children with a Glasgow Coma Scale score of <15, no documented pain or without a second pain score were excluded. The outcome measure was effective pain management (abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong-Baker FACES® scale or FLACC [face, legs, activity, crying and consolability] scale).

RESULTS

2312 patients were included for analysis. Median (IQR) age was 13 (9-16), 54% were male and the cause of pain was trauma in 66% of cases. Predictors of effective pain management include children who were younger (0-5 years) compared to older (12-17 years) (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.18-1.97), administered analgesia (AOR 2.26; CI 1.87-2.73), attended by a paramedic (AOR 1.46; CI 1.19-1.79) or living in an area of low deprivation (index of multiple deprivation [IMD] 8-10) compared to children in an area of high deprivation (IMD 1-3) (AOR 1.37; CI 1.04-1.80). Child sex, type of pain, transport time, non-pharmacological treatments and clinician experience were not significant.

CONCLUSION

These predictors highlight disparity in effective pre-hospital management of acute pain in children. Qualitative research is needed to help explain these findings.

Pre-hospital intranasal analgesia for children suffering pain: a rapid evidence review

Introduction:

Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. Studies have identified a number of barriers to pre-hospital pain management in children which include the route of analgesia administration. The aim of this review is to critically evaluate the pre-hospital literature, exploring the safety and efficacy of intranasal (IN) analgesics for children suffering pain.

Methods:

We performed a rapid evidence review, searching from inception to 17 December 2018, CINAHL, MEDLINE and Google Scholar. We included studies of children < 18 years suffering pain who were administered any IN analgesic in the pre-hospital setting. Our outcomes were effective pain management, defined as a pain score reduction of ≥ 2 out of 10, safety and rates of analgesia administration. Screening and risk of bias assessments were performed in duplicate. We performed a narrative synthesis.

Results:

From 310 articles screened, 23 received a full-text review resulting in 10 articles included. No interventional studies were found. Most papers reported on the use of intranasal fentanyl (INF) (n = 8) with one reporting IN ketamine and the other IN S-ketamine. Narrative synthesis showed that INF appeared safe and effective at reducing pain; however, its ability to increase analgesia administration rates was unclear. The effectiveness, safety and ability of IN ketamine and S-ketamine to increase analgesia administration rates were unclear. There was no evidence for IN diamorphine for children in this setting.

Conclusion:

Interventional studies are needed to determine with a higher confidence the effectiveness and safety of IN analgesics (fentanyl, ketamine, S-ketamine, diamorphine) for children in the pre-hospital setting.

A service evaluation of paediatric pain management in an English ambulance service

Introduction:

Evidence from the past 20 years has highlighted that acute pain is not managed well in the emergency setting, in particular with children. Inadequate management of pain can result in long-term changes in both physical and mental health. This service evaluation aimed to determine how paediatric pain is assessed and managed by ambulance clinicians in a large region in England.

Methods:

This retrospective service evaluation analysed electronic patient record (ePR) data routinely collected between September and December 2018. All paediatric patients (< 18 years of age) with pain documented narratively, or a pain score of ≥ 1/10, were included. The primary outcome measure was the proportion of patients with severe pain (defined as a pain score of ≥ 7/10) who achieve effective pain management (reduction in pain score of ≥ 2/10).

Results:

A total of 2801 paediatric patients who had documented pain were included in the analysis and the median age of patients was three years (interquartile range, 1–12 years). Most had a medical cause of pain (2387/2801, 85.2%), and analgesia was administered by the ambulance crew in 403/2801 (14.4%) patients. Multiple pain scores were recorded for 667 patients. Effective pain management was achieved in 233/271 (86%) patients in moderate pain and 204/210 (97.1%) patients in severe pain. However, of the 437 children in moderate to severe pain who achieved effective pain management, 381 (87%) received no analgesia.

Conclusion:

Children in severe pain received effective pain management, despite the majority not receiving any analgesia. This should be investigated further since non-pharmacological methods of analgesia are unlikely to explain a reduction of this magnitude. Ambulance staff need to be encouraged to record a pain score promptly after arriving on scene and ensure it is repeated. Pain score should be documented as part of the physiological observations and not in the free text of ePRs to ensure that it is identified during audits.

Fear memory-induced alterations in the mRNA expression of G proteins in the mouse brain and the impact of immediate posttraining treatment with morphine

Disturbances in fear-evoked signal transduction in the hippocampus (HP), the nuclei of the amygdala (AMY), and the prefrontal cortex (PFC) underlie anxiety-related disorders. However, the molecular mechanisms underlying these effects remain elusive. Heterotrimeric G proteins (GPs) are divided into the following four families based on the intracellular activity of their alpha subunit (Gα): Gα(s) proteins stimulate cyclic AMP (cAMP) generation, Gα(i/o) proteins inhibit the cAMP pathway, Gα(q/11) proteins increase the intracellular Ca⁺⁺ concentration and the inositol trisphosphate level, and Gα(12/13) proteins activate monomeric GP-Rho. In the present study, we assessed the effects of a fear memory procedure on the mRNA expression of the Gα subunits of all four GP families in the HP, AMY and PFC. C57BL/6 J mice were subjected to a fear conditioning (FC) procedure followed by a contextual or cued fear memory test (CTX-R and CS-R, respectively). Morphine (MOR, 1 mg/kg/ip) was injected immediately after FC to prevent the fear consolidation process. Real-time quantitative PCR was used to measure the mRNA expression levels of Gα subunits at 1 h after FC, 24 h after FC, and 1 h after the CTX-R or CS-R. In the HP, the mRNA levels of Gα(s), Gα(12) and Gα(11) were higher at 1 h after training. Gα(s) levels were slightly lower when consolidation was stabilized and after the CS-R. The mRNA levels of Gα(12) were increased at 1 h after FC, returned to control levels at 24 h after FC and increased again with the CTX-R. The increase in the Gα(11) level persisted at 24 h after FC and after CTX-R. In the AMY, no specific changes were induced by FC. In the PFC, CTX-R was accompanied by a decrease in Gα(i/o) mRNA levels; however, only Gα(i2) downregulation was prevented by MOR treatment. Hence, the FC-evoked changes in Gα mRNA expression were observed mainly in the HP and connected primarily to contextual learning. These results suggest that the activation of signaling pathways by Gα(s) and Gα(12) is required to begin the fear memory consolidation process in the HP, while signal transduction via Gα(11) is implicated in the maintenance of fear consolidation. In the PFC, the downregulation of Gα(i2) appears to be related to the contextual learning of fear.

The effects of trauma on brain and body: A unifying role for the midbrain periaqueductal gray

Post-traumatic stress disorder (PTSD), a diagnosis that may follow the experience of trauma, has multiple symptomatic phenotypes. Generally, individuals with PTSD display symptoms of hyperarousal and of hyperemotionality in the presence of fearful stimuli. A subset of individuals with PTSD; however, elicit dissociative symptomatology (i.e., depersonalization, derealization) in the wake of a perceived threat. This pattern of response characterizes the dissociative subtype of the disorder, which is often associated with emotional numbing and hypoarousal. Both symptomatic phenotypes exhibit attentional threat biases, where threat stimuli are processed preferentially leading to a hypervigilant state that is thought to promote defensive behaviors during threat processing. Accordingly, PTSD and its dissociative subtype are thought to differ in their proclivity to elicit active (i.e., fight, flight) versus passive (i.e., tonic immobility, emotional shutdown) defensive responses, which are characterized by the increased and the decreased expression of the sympathetic nervous system, respectively. Moreover, active and passive defenses are accompanied by primarily endocannabinoid- and opioid-mediated analgesics, respectively. Through critical review of the literature, we apply the defense cascade model to better understand the pathological presentation of defensive responses in PTSD with a focus on the functioning of lower-level midbrain and extended brainstem systems.

Outpatient opioid use of burn patients: A retrospective review

INTRODUCTION

Opioid overuse is a growing patient safety issue but continue to be integral to burn pain management. This study aims to characterize opioid use in discharged patients and factors for predictive of long term use.

METHODS

Participants with burns admitted to a single center from 2006 to 2015 were included. Total outpatient morphine equivalent dose (MED) was recorded at discharge and each clinic visit. Burn size, percent grafted, age, sex, and preadmission drug use were collected. For each time point, multivariate logistic regression was performed to examine the relationship of discharge MED and long-term opioid use, adjusting for age, sex, burn size, and percent grafted. MED was divided into low (0-150 mg per day), medium (151-300 mg per day), and high (greater than 301 mg) groups on day of discharge.

RESULTS

At discharge, 366 (90%) patients received opioids. At day 14, both the medium MED (OR 2.72; CI 1.18-6.23) and high MED (OR 2.74; CI 1.02-7.37) groups had an increased risk for continued opioid use. On day 60, only the high MED group (OR 6.06; CI 1.60-22.97) had an increased risk. History of drug use was significant at 60 days (OR 7.67; 1.67-35.26) and alcohol use was significant at 14 days (OR 3.14; CI 1.25-7.93) and 30 days (OR 5.92; CI 1.81-19.36).

CONCLUSIONS

Whereas opioids are widely prescribed upon discharge, most patients no longer use them 30 days later. Higher opiate utilization at discharge increases risk of long term use, as does pre-injury drug and alcohol use, but only temporarily.

Who Hurts More? A Multicenter Prospective Study of In-Hospital Opioid Use in Pediatric Trauma Patients in the Midwest

BACKGROUND

Despite increased national attention on misuse of prescription and nonprescription opioids for adolescents and children, little is known about opioid use in a pediatric population during hospitalization for injury. The purpose of this investigation is to describe opioid administration and magnitude of opioid exposure in the first 48 hours of hospitalization in a pediatric trauma population.

STUDY DESIGN

This is a secondary analysis of data collected for a randomized, prospective intervention study at 4 Midwestern children's trauma centers. Participants included children ages 10 to 17 years old, admitted to the hospital for unintentional injury. Descriptive statistics and multivariable modeling were used to characterize demographic factors and measure prevalence and magnitude of opioid use within the first 48 hours of hospitalization.

RESULTS

Among 299 participants, 82% received at least 1 opioid administration. Children had increased odds of receiving an opioid (odds ratio [OR] 4.25; 95% CI 2.16 to 8.35) for every log increase of Injury Severity Scores (ISS), yet the majority of children with minor injury (61%) also received an opioid. Children with fractures and older children had higher odds of receiving an opioid. Amount of opioid, expressed as morphine milligrams equivalent (MME), significantly increased with child age, ISS, and fracture.

CONCLUSIONS

Most pediatric trauma patients received an opioid in the first 48 hours of hospitalization, although prevalence and exposure varied by age, injury, and acuity. Aggressive pain management can be appropriate for injured pediatric patients; however, study results indicate areas for improvement, specifically for children with minor injuries and those receiving excessive opioid amounts.

Theranostic pharmacology in PTSD: Neurobiology and timing

Recent reviews and treatment guidelines regard trauma-focused cognitive-behavior therapies as the treatments of choice for chronic post-traumatic stress disorder (PTSD). However, many patients do not engage in this treatment when it is available, drop out before completion, or do not respond. Medications remain widely used, alone and in conjunction with psychotherapy, although the limitations of traditional monoamine-based pharmacotherapy are increasingly recognized. This article will review recent developments in psychopharmacology for PTSD, with a focus on current clinical data that apply putative neurobiologic mechanisms to medication use-i.e., a theranostic approach. A theranostic approach however, also requires consideration of timing, pre, peri or post trauma in conjunction with underlying dynamic processes affecting synaptic plasticity, the HPA axis, hippocampal activation, PFC-amygdala circuitry and fear memory.

Time-dependent protective effects of morphine against behavioral and morphological deficits in an animal model of posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) arises after an individual has experienced a major traumatic event. Recent evidence suggests that acute morphine treatment may serve as a strategy to reduce PTSD development. In the present study, we investigated the time-dependent effects of morphine on behavioral and morphological deficits induced by the single prolonged stress (SPS), an experimental model of PTSD, in adult male rats. The rats were exposed to SPS (restraint for 2 h, forced swimming for 20 min, and ether anesthesia), and kept undistributed for 11 days. Morphine was injected immediately, 6, 12 and 24 h after SPS. Anxiety profile was evaluated using the elevated plus maze11 days after SPS. Then, animals were conditioned in a fear conditioning task and extinction training was performed on days 1, 2, 3, 4 and 11 after fear conditioning which followed by morphological assessments in the medial prefrontal cortex (mPFC). SPS rats showed increased anxiety levels and impaired contextual fear extinction retention. SPS also decreased dendritic length in the infra-limbic (IL) and dendritic spines in the IL and pre-limbic (PL) regions of the mPFC. Conversely, morphine treatment 6, 12 and 24 h but not immediately after SPS significantly improved anxiety-like behaviors, fear extinction, increased dendritic length, and spines in the mPFC. Morphine-induced much stronger response when injected 24 h after the SPS, and this effect was blocked by naloxone. Our findings show that morphine within a restricted time window selectively reversed the SPS-induced deficits in anxiety profile, fear extinction, and dendritic morphology in the mPFC. Finally, these findings suggest that the time point of morphine injection following a traumatic event is an important determinant of the full therapeutic effect of morphine against PTSD.

Trauma-Informed Care for Violently Injured Patients in the Emergency Department

Violent traumatic injury remains a common condition treated by emergency physicians. The medical management of these patients is well described and remains an area of focus for providers. However, violently injured patients disproportionately carry a history of physical and psychological trauma that frequently affects clinical care in the emergency department. The alteration of our clinical approach, taking into consideration how a patient's previous experiences influence how he or she may perceive and react to medical care, is a concept referred to as trauma-informed care. This approach is based on 4 pillars: knowledge of the effect of trauma, recognition of the signs and symptoms of trauma, avoidance of retraumatization, and the development of appropriate policies and procedures. Using this framework, we provide practical considerations for emergency physicians in the delivery of trauma-informed care for violently injured patients.

Opioidergic Regulation of Emotional Arousal: A Combined PET–fMRI Study

Emotions can be characterized by dimensions of arousal and valence (pleasantness). While the functional brain bases of emotional arousal and valence have been actively investigated, the neuromolecular underpinnings remain poorly understood. We tested whether the opioid and dopamine systems involved in reward and motivational processes would be associated with emotional arousal and valence. We used in vivo positron emission tomography to quantify μ-opioid receptor and type 2 dopamine receptor (MOR and D2R, respectively) availability in brains of 35 healthy adult females. During subsequent functional magnetic resonance imaging carried out to monitor hemodynamic activity, the subjects viewed movie scenes of varying emotional content. Arousal and valence were associated with hemodynamic activity in brain regions involved in emotional processing, including amygdala, thalamus, and superior temporal sulcus. Cerebral MOR availability correlated negatively with the hemodynamic responses to arousing scenes in amygdala, hippocampus, thalamus, and hypothalamus, whereas no positive correlations were observed in any brain region. D2R availability—here reliably quantified only in striatum—was not associated with either arousal or valence. These results suggest that emotional arousal is regulated by the MOR system, and that cerebral MOR availability influences brain activity elicited by arousing stimuli.

A Review of the Neurobiological Basis of Trauma-Related Dissociation and Its Relation to Cannabinoid- and Opioid-Mediated Stress Response: a Transdiagnostic, Translational Approach

Dissociative experiences have been associated with increased disease severity, chronicity, and, in some cases, reduced treatment response across trauma-related and other psychiatric disorders. A better understanding of the neurobiological mechanisms through which dissociative experiences occur may assist in identifying novel pharmacological and non-pharmacological treatment approaches. Here, we review emerging work on the dissociative subtype of posttraumatic stress disorder (PTSD), and other trauma-related disorders providing evidence for two related overarching neurobiological models of dissociation, the defense cascade model of dissociation and Mobb's threat detection model. In particular, we review neuroimaging studies highlighting alterations in functional connectivity of key brain regions associated with these models, including connectivity between the prefrontal cortex, the amygdala and its complexes, the insula, and the periaqueductal gray. Work implicating the kappa-opioid and endocannabinoid systems in trauma-related dissociative experiences is also reviewed. Finally, we hypothesize mechanisms by which pharmacological modulation of these neurochemical systems may serve as promising transdiagnostic treatment modalities for individuals experiencing clinically significant levels of dissociation. Specifically, whereas kappa-opioid receptor antagonists may serve as a pharmacological vehicle for the selective targeting of dissociative symptoms and associated emotion overmodulation in the dissociative subtype of posttraumatic stress disorder and transdiagnostically, modulation of the endocannabinoid system may reduce symptoms associated with emotional undermodulation of the fight or flight components of the defense cascade model.

What are the predictors, barriers and facilitators to effective management of acute pain in children by ambulance services? A mixed-methods systematic review protocol

Introduction

The management of pain is complex, especially in children, as age, developmental level, cognitive and communication skills and associated beliefs must be considered. Without effective pain treatment, children may suffer long-term changes in stress hormone responses and pain perception and are at risk of developing posttraumatic stress disorder. Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. The aim of this review is to identify predictors, barriers and facilitators to effective management of acute pain in children by ambulance services.

Methods

A mixed-methods approach has been adopted due to the research question lending itself to qualitative and quantitative inquiry. The segregated methodology will be used where quantitative and qualitative papers are synthesised separately, followed by mixed-methods synthesis (meta-integration). We will search from inception: MEDLINE, CINAHL and PsycINFO via EBSCOHost, EMBASE via Ovid SP, Web of Science and Scopus. The Cochrane Library, the Joanna Briggs Institute, PROSPERO, ISRCTN and ClinicalTrials.gov will be searched. We will include empirical qualitative and quantitative studies. We will exclude animal studies, reviews, audits, service evaluations, simulated studies, letters, Best Evidence Topics, case studies, self-efficacy studies, comments and abstracts. Two authors will perform full screening and selection, data extraction and quality assessment. GRADE and CERQual will determine the confidence in cumulative evidence.

Discussion

If confidence in the cumulative evidence is deemed Moderate, Low or Very Low, then this review will inform the development of a novel mixed-methods sequential explanatory study which aims to comprehensively identify predictors, barriers and facilitators to effective pain management of acute pain in children within ambulance services. Future research will be discussed among authors if confidence is deemed High.Systematic Review Registration: PROSPERO: CRD42017058960.

Procedural sedation in non-intubated children with severe trauma - A single center study

BACKGROUND

Non-intubated children frequently undergo emergent procedures in the trauma-bay. This study evaluates whether patients treated with procedural sedation have an increased risk for severe adverse events.

METHODS

Retrospective analysis of 1182 children with an injury severity score (ISS) of greater than 15.

RESULTS

Of the 565 patients who were spontaneously breathing on arrival, 455 were hemodynamically stable with a Glasgow Coma Score of 15, 201 of whom were treated with sedation; 144 (71.6%) had computerized tomography scan, 35 (17.5%) wound debridement, and 22 (10.9%) fracture reduction. Sedation patients had an ISS of 20 (interquartile range 17-25). There were no death cases, no cases of cardiopulmonary resuscitation, and no cases of neurologic sequelae on hospital discharge. There were 2 (1%) cases of unanticipated endotracheal intubation.

CONCLUSIONS

Non-intubated patients who were hemodynamically stable with a Glasgow Coma Score of 15 had a low risk for severe adverse events due to sedation.

Pain Experience in a US Children's Hospital: A Point Prevalence Survey Undertaken After the Implementation of a System-Wide Protocol to Eliminate or Decrease Pain Caused by Needles

OBJECTIVES

Pain in hospitalized children remains under-assessed and undertreated. With this study, we aim to describe results from a repeat single-day, hospital-wide survey of children's pain and its treatment after the initiation of a hospital-wide quality improvement initiative used to reduce or eliminate pain caused by needle procedures.

METHODS

All patients and parents listed on the inpatient morning census, in emergency department and outpatient surgery registration lists, were invited to participate in a brief single-day point prevalence survey of their experience with pain and its management in the hospital setting. Results were compared with a survey conducted 2 years earlier, before implementation of a system-wide Children's Comfort Promise needle pain treatment and prevention protocol.

RESULTS

A total of 194 children and their parents participated in the current survey. A higher percentage of children reported having no pain compared with the previous survey (33% vs 24%; P = .07; not significant) and fewer experienced severe pain (score ≥7 out of 10). Fewer children identified pain caused by needles as the cause of the worst pain (21% vs 30%), although it remained the highest reported cause of the most painful experience overall. The number of pain management strategies administered and offered to children with needle pain (distraction, positioning, numbing cream, and sucrose and/or breastfeeding for infants) increased.

CONCLUSIONS

The implementation of a mandatory Comfort Promise protocol used to minimize or prevent pain caused by elective needle procedures was associated with a significant reduction in overall pain prevalence and improved use of evidence-based practices for needle pain management.