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Agoston AM, Bleacher J, Smith A, Edwards S, Routly M. Longitudinal Associations Between Pain, Risk for Posttraumatic Stress Disorder, Posttraumatic Stress Symptoms, and Pain Characteristics in Children After Unintentional Injury. Clin J Pain 2024; 40:400-408. [PMID: 38499983 DOI: 10.1097/ajp.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 03/10/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVES Approximately 20% of children demonstrate persistent posttraumatic stress symptoms (PTSS) after unintentional injury, with more severe pain intensity predicting concurrent and later PTSS. Examining additional pain characteristics like pain behaviors, impairment related to pain, and subjective experiences of pain might provide additional insight into the mechanisms that reinforce relationships between risk for posttraumatic stress disorder (PTSD), PTSS, and pain. METHODS During hospitalization for unintentional injury, the Screening Tool for Predictors of PTSD (STEPP) was administered and the highest pain score was collected. One month later, the Child PTSD Symptom Scale and PROMIS questionnaires assessed PTSS and pain characteristics respectively, including intensity, interference, behaviors, and quality. RESULTS Correlations between PTSS and PROMIS questionnaires were significant. STEPP predicted future PTSS and all PROMIS questionnaires. The highest pain score predicted future PTSS, as well as pain interference and pain behavior, and did not predict pain intensity and pain quality. When STEPP and highest pain score were combined into a single regression, STEPP and highest pain score predicted future PTSS but only STEPP continued to predict all PROMIS questionnaires. DISCUSSION PTSD risk significantly predicted PTSS and pain characteristics 1 month later. The highest pain score predicted future PTSS and several pain characteristics but no longer had predictive value for pain-related outcomes when combined with PTSD risk. These results indicate that risk factors for PTSD are stronger predictors than pain-related risk factors in predicting pain outcomes. Addressing PTSD risk, as well as pain intensity during hospitalization, may result in improved outcomes for children with unintentional injury.
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Affiliation(s)
- Anna Monica Agoston
- Center for Pain Relief
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
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Frawley J, Goyal A, Gappy R, Sandoval S, Chen NW, Crowe R, Swor R. A Comparison of Prehospital Pediatric Analgesic Use of Ketamine and Opioids. PREHOSP EMERG CARE 2023; 27:915-919. [PMID: 36857195 DOI: 10.1080/10903127.2023.2183295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/15/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE/INTRODUCTION Ketamine is an opioid-alternative used for analgesia in the prehospital setting. There are knowledge gaps regarding its use during emergency medical services (EMS) encounters for pediatric patients. Our objective was to compare pain reduction, adverse events, and prehospital deaths between ketamine and opioids when used for analgesia administered by any route among pediatric patients. METHODS This was a retrospective review of 9-1-1 EMS records of injured pediatric patients (≤17 years of age) who received ketamine or opioids for analgesia using the ESO Data Collaborative (calendar years 2019-2020). We excluded interfacility transfers, patients receiving both medications, those with EMS clinician impressions indicating behavioral disorders, and those who received medication to facilitate advanced airway placement. EMS narrative review was performed to confirm ketamine use was for analgesia and to identify any unplanned airway placements. We assessed pain score reduction (0-10 ordinal scale) and clinician-documented patient response (improved, unchanged, worsened, unknown). Adverse events were defined as change in vital signs (GCS, SBP, RR, SpO2), bag valve mask ventilation alone, or death. Descriptive statistics were calculated to compare outcomes between groups. RESULTS Overall, 9,223 patients were included, 190 (2.1%) received ketamine and 9,033 (97.9%) received opioids. Mean age in years was 12.8 [SD 4.0] for ketamine and 12.7 [SD 4.0] for opioids. Patients in both groups experienced pain reduction, and more patients receiving ketamine had EMS clinician reported improvement (93.2% vs. 87.9%, p = 0.03). Ketamine was associated with a greater average reduction in pain score than opioids (mean difference: -4.4 [SD 3.5], and -3.1 [SD 2.8], p < 0.001). Adverse events were rare with few patients receiving ventilatory support following the use of ketamine or opioids, (0, [SD 0.0%] vs. 6 [SD 0.1%], p = 1). There were no unplanned airway placements or prehospital deaths identified. CONCLUSION We identified similar high rates of pain reduction and rare adverse events among pediatric patients who received ketamine or opioids. A greater pain reduction was noted among patients administered ketamine. Intubation as a result of medication administration did not occur and need for ventilatory assistance was rare.
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Affiliation(s)
- John Frawley
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Ashima Goyal
- Division of Pediatric Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Revelle Gappy
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Sariely Sandoval
- Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Nai-Wei Chen
- Division of Bioinformatics, Beaumont Research Institute, Royal Oak, Michigan
| | | | - Robert Swor
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
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Agoston AM, Bhatia A, Bleacher JC, Smith A, Hill K, Edwards S, Cochran A, Routly M. PTSD Risk Factors and Acute Pain Intensity Predict Length of Hospital Stay in Youth after Unintentional Injury. CHILDREN 2022; 9:children9081222. [PMID: 36010111 PMCID: PMC9406594 DOI: 10.3390/children9081222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/27/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022]
Abstract
Background: Many hospitals have adopted screening tools to assess risk for posttraumatic stress disorder (PTSD) after pediatric unintentional injury in accordance with American College of Surgeons recommendations. The Screening Tool for Early Predictors of PTSD (STEPP) is a measure initially developed to identify youth and parents at high risk for meeting diagnostic criteria for PTSD after injury. Acute pain during hospitalization has also been examined as a potential predictor of maladaptive outcomes after injury, including PTSD. We investigated in a retrospective cohort study whether the STEPP, as well as acute pain intensity during hospitalization, would predict maladaptive outcomes during the peri-trauma in addition to the post-trauma period, specifically length of hospitalization. Methods: A total of 1123 youths aged 8–17 (61% male) and their parents were included. Patients and parents were administered the STEPP for clinical reasons while hospitalized. Acute pain intensity and length of stay were collected through retrospective chart review. Results: Adjusting for demographics and injury severity, child but not parent STEPP total predicted length of stay. Acute pain intensity, child threat to life appraisal, and child pulse rate predicted length of stay. Conclusions: Acute pain intensity and child PTSD risk factors, most notably child threat to life appraisal, predicted hospitalization length above and beyond multiple factors, including injury severity. Pain intensity and child appraisals may not only serve as early warning signs for maladaptive outcomes after injury but also indicate a more difficult trajectory during hospitalization. Additional assessment and treatment of these factors may be critical while youth are hospitalized. Utilizing psychology services to support youth and integrating trauma-informed care practices during hospitalization may support improved outcomes for youth experiencing unintentional injury.
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Affiliation(s)
- Anna Monica Agoston
- Center for Pain Relief, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
- Division of Pediatric Anesthesiology, Emory University, Atlanta, GA 30322, USA
- Correspondence: ; Tel.: +1-503-830-4305; Fax: +1-404-785-6223
| | - Amina Bhatia
- Division of Surgery, Emory University, Atlanta, GA 30322, USA
| | - John C. Bleacher
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Alexis Smith
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Karen Hill
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Susanne Edwards
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Alicia Cochran
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Maia Routly
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
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Kerbage H, Bazzi O, El Hage W, Corruble E, Purper-Ouakil D. Early Interventions to Prevent Post-Traumatic Stress Disorder in Youth after Exposure to a Potentially Traumatic Event: A Scoping Review. Healthcare (Basel) 2022; 10:healthcare10050818. [PMID: 35627955 PMCID: PMC9141228 DOI: 10.3390/healthcare10050818] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/19/2022] [Accepted: 04/25/2022] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Hala Kerbage
- Department of Child and Adolescent Psychiatry, Saint Eloi University Hospital, 34090 Montpellier, France
- Center for Epidemiology and Population Health (CESP), INSERM U1018, Developmental Psychiatry Team, Paris-Saclay University, Villejuif CEDEX, 94807 Paris, France
- Correspondence: ; Tel.: +33601819449
| | - Ola Bazzi
- Faculty of Health Sciences, American University of Beirut, Beirut 1107 2020, Lebanon;
| | - Wissam El Hage
- Center of Clinical Investigation iBrain 1253, University of Tours, 37032 Tours, France;
| | - Emmanuelle Corruble
- CESP, MOODS Team, INSERM U1018, School of Medicine, Paris-Saclay University, Kremlin Bicetre, 94275 Paris, France;
- Department of Psychiatry, Paris-Saclay University Hospital, Kremlin Bicetre, 94275 Paris, France;
| | - Diane Purper-Ouakil
- Department of Psychiatry, Paris-Saclay University Hospital, Kremlin Bicetre, 94275 Paris, France;
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Brandehoff N, Benjamin JM, Balde C, Chippaux JP. Ketamine for pain control of snake envenomation in Guinea: A case series. Toxicon 2020; 187:82-85. [PMID: 32891662 DOI: 10.1016/j.toxicon.2020.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/11/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022]
Abstract
Snakebite envenomation is a global health crisis and is classified as a Category A neglected tropical disease by the World Health Organization (WHO). Snakebite envenomations account for a significant amount of morbidity and morbidity in tropical and subtropical regions. Recently, publications have illustrated the potential for snake envenomations causing post-traumatic stress disorder (PTSD) in a significant number of patients. Ketamine is on the WHO's list of essential medications and is used for a variety of pharmacologic applications including anesthesia and acute pain management. To date it has not been assessed for pain control in snakebite envenomations. Twelve patients who presented with severe pain secondary to Bitis, Causus, and Atractaspis envenomations were treated with low-dose intravenous ketamine. The patients included 7 males and 5 females with a median age of 37.5 (range 14-64) and a median presentation time of 5.75 h (range 5 min-96 h) after the initial bite occurred. Ten envenomations were presumed to have been caused by Bitis species resulting in extensive swelling and blistering of the affected extremities. One envenomation was presumedC. maculatus causing local swelling and pain. One envenomation was a presumed Atractaspis species causing significant local pain with minimal swelling. All patients expressed having significant pain but could not express the degree of their pain using an analogue pain scale. An initial median dose of 5 mg of ketamine (range 2.5-15 mg) was administered intravenously for pain control. Every patient expressed decreased pain and felt more comfortable within 1 min after administration of ketamine. Nine of the twelve patients only required a single dose. There were no adverse side effects. Ketamine appears to be an effective means of pain control for those suffering from painful envenomations. With minimal risk of significant side effects at acute pain management doses and the average cost per effective dose averaging between US$0.03-0.06, this may provide a cheap, safe, and effective solution for Sub-saharan Africa and other resource-limited settings. Controlled studies need to be done to critically assess our observations.
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Affiliation(s)
- Nicklaus Brandehoff
- Asclepius Snakebite Foundation, 217 Howard St, Walla Walla, WA, 99362, USA; University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO, 80045, USA; Rocky Mountain Poison and Drug Safety, 1391 Speer Blvd, Denver, CO, 80204, USA.
| | - Jordan Max Benjamin
- Asclepius Snakebite Foundation, 217 Howard St, Walla Walla, WA, 99362, USA; Whitman College, 345 Boyer Ave, Walla Walla, WA, 99362, USA
| | - Cellou Balde
- Asclepius Snakebite Foundation, 217 Howard St, Walla Walla, WA, 99362, USA; Institut de Recherche en Biologie Appliqueé de Guinée (IRBAG), Conakry, Guinea
| | - Jean-Philippe Chippaux
- Asclepius Snakebite Foundation, 217 Howard St, Walla Walla, WA, 99362, USA; Institute of Research for Development, Paris, France
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