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Eimer C, Reifferscheid F, Jung P, Rudolph M, Terboven T, Hoffmann F, Lorenzen U, Köser A, Seewald S. Pre-hospital analgesia in pediatric trauma and critically ill patients: An analysis of a German air rescue service. Scand J Trauma Resusc Emerg Med 2023; 31:5. [PMID: 36709289 PMCID: PMC9883913 DOI: 10.1186/s13049-023-01069-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 01/22/2023] [Indexed: 01/30/2023] Open
Abstract
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).
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Affiliation(s)
- Christine Eimer
- grid.412468.d0000 0004 0646 2097Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, 24105 Kiel, Germany
| | - Florian Reifferscheid
- grid.412468.d0000 0004 0646 2097Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, 24105 Kiel, Germany ,Department of Pediatrics, German Air Rescue Service Association “DRF Luftrettung”, Filderstadt, Germany
| | - Philipp Jung
- grid.412468.d0000 0004 0646 2097University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marcus Rudolph
- Department of Pediatrics, German Air Rescue Service Association “DRF Luftrettung”, Filderstadt, Germany ,grid.411778.c0000 0001 2162 1728Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Mannheim, Mannheim, Germany
| | - Tom Terboven
- grid.492141.bDepartment of Anaesthesiology and Critical Care Medicine, St. Josefskrankenhaus, Heidelberg, Germany
| | - Florian Hoffmann
- grid.411095.80000 0004 0477 2585Dr. Von Hauner University Children’s Hospital, Munich, Germany
| | - Ulf Lorenzen
- grid.412468.d0000 0004 0646 2097Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, 24105 Kiel, Germany
| | - Andrea Köser
- grid.412468.d0000 0004 0646 2097Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, 24105 Kiel, Germany
| | - Stephan Seewald
- grid.412468.d0000 0004 0646 2097Department of Anesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, 24105 Kiel, Germany ,grid.412468.d0000 0004 0646 2097Department of Emergency Medicine, University Medical Centre Schleswig-Holstein, Kiel, Germany
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Ruffin TB, Salinero E, Papa L, Cramm K, Florez C, Chen JG, Ramirez J. Intranasal Fentanyl to Reduce Pain and Improve Oral Intake in the Management of Children With Painful Infectious Mouth Lesions. Pediatr Emerg Care 2022; 38:363-366. [PMID: 35802483 DOI: 10.1097/pec.0000000000002779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused and immediately spit back out. This study evaluated the efficacy of intranasal fentanyl (INF) compared with a commonly used oral (PO) acetaminophen/hydrocodone formulation for the treatment of children with painful infectious mouth conditions. METHODS This study was a prospective, nonblinded, randomized controlled noninferiority trial conducted in an academic tertiary care pediatric emergency department. The study enrolled children between the ages of 6 months and 18 years with painful infectious mouth lesions and poor oral intake. Patients were randomized to receive either INF (1.5 μg/kg, intervention) or PO acetaminophen/hydrocodone (0.15 mg/kg, control) based on the dose of hydrocodone. The primary outcome was volume of fluid intake per body weight (in milliliters per kilogram) 60 minutes after analgesic administration. Secondary outcomes included pain scores using a validated visual assessment scale (VAS; 1, no pain; 10, worst pain), hydration score (VAS; 1, well hydrated; 4, very dehydrated), admission rate and overall satisfaction score (VAS; 1, worst; 7, best). A priori power analysis indicated that 34 patients would achieve an 81% power with an α value of 0.05. RESULTS Of the 34 patients enrolled, 17 were randomized to INF and 17 to PO. The demographics between both groups were similar in age, weight, sex, and race. There were no significant differences in parental perception of pain ( P = 0.69) or hydration status ( P = 0.78). Oral fluid intake at 60 minutes was 20 mL/kg for INF versus 18 mL/kg for PO ( P = 0.53). Pain scores at 15 and 30 minutes were 1.7 versus 2.9 ( P = 0.09) and 0.6 versus 1.6 ( P = 0.59). Parental perceptions of pain and hydration status at 60 minutes were 2.2 versus 2.4 ( P = 0.77) and 1.7 versus 1.5 ( P = 0.37). Overall parental satisfaction was 6.4 for INF versus 6.5 for PO ( P = 0.71), and admission rate was 0 vs 12% ( P = 0.49). There were no adverse events such as respiratory, cardiac, or central nervous system depression in either group. CONCLUSIONS Intranasal fentanyl seems to be a safe and effective alternative to acetaminophen with hydrocodone in reducing pain and improving hydration status in children with painful infectious mouth lesions and poor oral intake.
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Affiliation(s)
- Thomas B Ruffin
- From the Arnold Palmer Hospital for Children, Orlando Health
| | - Efren Salinero
- From the Arnold Palmer Hospital for Children, Orlando Health
| | | | - Kelly Cramm
- From the Arnold Palmer Hospital for Children, Orlando Health
| | - Camilo Florez
- From the Arnold Palmer Hospital for Children, Orlando Health
| | - J Gene Chen
- From the Arnold Palmer Hospital for Children, Orlando Health
| | - Jose Ramirez
- From the Arnold Palmer Hospital for Children, Orlando Health
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Edmonds J, Bignell M, Coward P, Leonard S, Wolten E. Managing children's forearm fractures in the emergency department. Emerg Nurse 2022; 30:18-23. [PMID: 34490764 DOI: 10.7748/en.2021.e2099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/09/2022]
Abstract
Forearm fractures are the most common fractures among children and young people aged up to 19 years and these patients frequently present to the emergency department (ED). Many of these fractures can be treated in the ED without the need for inpatient admission. This article examines the assessment, diagnosis and management of forearm fractures. The authors also use a case study format to demonstrate best practice in the treatment of forearm fractures in this age group. The information in this article will enable ED nurses to enhance the experience of children and their families who present with forearm fractures.
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Affiliation(s)
- Jenny Edmonds
- Children's Emergency Department, Paediatrics, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, England
| | - Matilda Bignell
- Children's Emergency Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, England
| | - Phoebe Coward
- Children's Emergency Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, England
| | - Sarah Leonard
- Children's Emergency Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, England
| | - Emma Wolten
- Children's Emergency Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, England
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Tan SM, Ong YKG, Pek JH. Analgesia for extremity fractures in the paediatric emergency department. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820915731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Extremity fractures are an important and common presentation at the Paediatric Emergency Department (PED). Provision of analgesia is a key management principle, but it is often suboptimal. Although there is an increase in awareness of this issue, the impact on current practice is not known. We aimed to review the current practice of providing analgesia for extremity fractures in the PED. Objective: Our objective was to determine the utilisation, adequacy and timeliness of analgesia provided for these patients. Methods: A retrospective study was carried out from November to December 2017. Patients with a diagnosis of extremity fracture involving the upper or lower limb were included. Information about patient demographics, diagnosis, pain score, analgesia use and clinical progress were collected for analysis. Results: There were 101 cases. The mean age was 8.5±4.2 years old, and 62 (61.4%) patients were male. There were 76 (75.3%) cases of fractures involving the upper limb, and 25 (24.7%) cases of fractures involving the lower limb. The mean pain score at presentation was 3.3±2.3. Analgesia was administered to only 10 (9.9%) patients, with oral paracetamol ( n=5; 5.0%) being the most common medication administered. The median time between arrival in the PED to analgesia administration was 69 minutes (range 25–328 minutes). Conclusions: Despite the increase in awareness, analgesia for these patients remains underutilised, inadequate and delayed. Further efforts at pain assessment, analgesia selection and administration are necessary to improve the provision of analgesia for these patients.
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Affiliation(s)
- Siew Ming Tan
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore
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Tan D, Xia H, Sun S, Wang F. Effect of ancillary drugs on sevoflurane related emergence agitation in children undergoing ophthalmic surgery: a Bayesian network meta-analysis. BMC Anesthesiol 2019; 19:138. [PMID: 31370793 PMCID: PMC6670177 DOI: 10.1186/s12871-019-0810-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/25/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The comparative efficacy of ancillary drugs on sevoflurane related emergence agitation (EA) in children undergoing ophthalmic surgery remains controversial. METHODS The databases were retrieved in an orderly manner from the dates of their establishment to October, 2018, including PubMed, The Cochrane Library and Web of Science, to collect randomized controlled trials (RCT) of different anesthetic drugs combined with sevoflurane for ophthalmic surgery. Then a network meta-analysis was conducted using R and Stata 12.0 softwares. RESULTS The meta-analysis showed that, in reducing sevoflurane related EA, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil and clonidine were superior to placebo (P < 0.05). The network meta-analysis showed that the effects of ancillary drugs combine with sevoflurane in reducing risk of EA in children undergoing ophthalmic surgery was superior to placebo: dexmedetomidine (OR = 0.17, 95% CrI 0.12-0.22), ketamine (OR = 0.30, 95% CrI 0.11-0.49), propofol (OR = 0.24, 95% CrI 0.09-0.63), fentanyl (OR = 0.16, 95% CrI 0.08-0.56), midazolam (OR = 0.20, 95% CrI 0.09-0.40), sufentanil (OR = 0.27, 95% CrI 0.14-0.41), remifentanil (OR = 0.18, 95% CrI 0.08-0.54) and clonidine (OR = 0.14, 95% CrI 0.07-0.41). The SUCRA of placebo, dexmedetomidine, ketamine, propofol, fentanyl, midazolam, sufentanil, remifentanil, clonidine were respectively 0.26, 77.93, 27.71, 42.8, 69.43, 52.89, 59.83, 57.62 and 61.53%. CONCLUSIONS The effects of dexmedetomidine combine with sevoflurane in reducing risk of emergence agitation in children undergoing ophthalmic surgery was superior to other drugs.
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Affiliation(s)
- Dan Tan
- Editorial Office, Journal of New Medicine, Zhongnan Hospital of Wuhan University, No.169 Donghu Road, Wuchang District, Wuhan, 430071, Hubei Province, China.
| | - Haifa Xia
- Department of Anesthesiology, Institute of Anesthesia and Critical Care, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shujun Sun
- Department of Anesthesiology, Institute of Anesthesia and Critical Care, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fuquan Wang
- Department of Anesthesiology, Institute of Anesthesia and Critical Care, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Kim KS, Yu SC, Han JW, Shim SM, Kwak S, Kim YM, Kim SS. Effect of fentanyl nasal packing treatment on patients with acute postoperative pain after closed reduction of nasal bone fracture: a randomized double-blind controlled trial. J Plast Surg Hand Surg 2019; 53:167-172. [PMID: 30734629 DOI: 10.1080/2000656x.2019.1566738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Nasal bone fracture reduction surgery is normally followed by nasal packing to control bleeding. Yet, patients suffer from pain and require further analgesic treatments following nasal packing and removal. This study aimed to evaluate the effect of fentanyl-soaked packing as a method of controlling pain after nasal surgeries in a prospective, randomized, double-blind controlled trial. METHODS Sixty-five patients that have undergone closed nasal bone fracture reduction surgery were included in this study. Thirty-two patients were treated postoperatively with 50 mcg fentanyl-soaked Merocel®, a biodegradable synthetic polyurethane foams packing, and the other 33 patients were treated with saline-soaked packings. To analyze the relative nasal pain control effect of fentanyl, Numeric Rating Scale, patient satisfaction and Ramsay Sedation Scale were used. Patients were closely monitored to record relevant cardiopulmonary indicators and degree of adverse symptoms such as headache or sore throat. RESULTS Fentanyl group had a significantly lower Numeric Rating Scale and higher patient satisfaction for most of the time periods after operation (p < .05). Symptoms of headache and sore throat were also significantly reduced. Ramsay Sedation Scale scores improved compared to the control group (p < .05). No significant differences in cardiopulmonary relevant indicators between the two experimental groups were observed (p > .05). CONCLUSION Fentanyl-soaked packing significantly decreased postoperative pain with no observable adverse effects. Our results demonstrate that topical fentanyl application to nasal packing is an effective method of postoperative pain control after closed nasal bone fracture reduction surgery.
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Affiliation(s)
- Kwan-Sub Kim
- a Department of Anesthesiology and Pain Medicine, Dongkang Medical Center , Ulsan , South Korea
| | - Sung Chul Yu
- b Department of Plastic Surgery, Gangneung Asan Medical Center , University of Ulsan College of Medicine , Seoul , Korea
| | - Jung-Woo Han
- c Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center , University of Ulsan College of Medicine , Seoul , Korea
| | - Sung-Min Shim
- c Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center , University of Ulsan College of Medicine , Seoul , Korea
| | - Soohyun Kwak
- d Department of Rehabilitation Medicine, Semin hospital , Seoul , Korea
| | - Yong-Min Kim
- e The Hong Kong University of Science and Technology , Clear Water Bay , Hong Kong
| | - Seong-Su Kim
- c Department of Anesthesiology and Pain Medicine, Gangneung Asan Medical Center , University of Ulsan College of Medicine , Seoul , Korea
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Schoolman-Anderson K, Lane RD, Schunk JE, Mecham N, Thomas R, Adelgais K. Pediatric emergency department triage-based pain guideline utilizing intranasal fentanyl: Effect of implementation. Am J Emerg Med 2018; 36:1603-1607. [DOI: 10.1016/j.ajem.2018.01.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022] Open
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Setlur A, Friedland H. Treatment of pain with intranasal fentanyl in pediatric patients in an acute care setting: a systematic review. Pain Manag 2018; 8:341-352. [PMID: 30278812 DOI: 10.2217/pmt-2018-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM The primary objective of this review is to provide an updated, comprehensive overview on the efficacy of intranasal fentanyl (INF) for acute pain relief in the pediatric population. METHODS Utilizing the Preferred Reporting Instructions for Systematic Reviews and Meta-Analyses (PRISMA), we were able to screen articles based on key words to reach a final number of 10 studies. RESULTS All but one study showed that INF was efficacious for pain relief in this select pediatric population. CONCLUSION It is evident that INF is efficacious for analgesia, but other agents should also be considered in this patient population. As a result, further research is needed to investigate the clinically efficacy of INF in an acute care setting for pediatric patients.
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Affiliation(s)
- Anuradha Setlur
- Department of Pediatrics, St. Joseph's Medical Center, Paterson, NJ 07503, USA
| | - Howard Friedland
- Department of Pediatrics, St. Joseph's Medical Center, Paterson, NJ 07503, USA
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