ORIGINAL CONTRIBUTION analgesics; pain
Analgesic Use in the Emergency Department The relief of pain is one of the most common reasons for seeking care in an emergency department. We conducted a retrospective chart review to see whether children received analgesic treatment similar to that of adults with the same acute, painful conditions. Charts of 112 pediatric patients from the Children's Hospital of Philadelphia ED and 156 patients from the Medical College of Pennsylvania ED were reviewed. Patient ages ranged from a few months to 97 years. All patients had acute pain due to sickle cell crises (20%), lower-extremity fractures (31%), or second-or third-degree burns (49%). Hospitalization was required in 15% of cases. In the ED, 60% of patients with painful conditions received no pain medications at aiI. When medications were given, they were usually narcotics. Children (aged I9 years or younger) were much less likely to receive pain medications than adults (P = .001). Those less than 2 years old received analgesics less often than older children (P < .01). Senior citizens (aged 65 years or older) received analgesics as often as other adults. On discharge from the ED, 55% of all patients had no pain medications prescribed; and children were less likely than adults to receive analgesics at discharge (P < .001). Pediatricians and emergency physicians are reluctant to use analgesics ,for children in pain. The data suggest that these physicians need additional education about management of acute pain. [Selbst SM, Clark M: Analgesic use in the emergency department. Ann Emerg Med September 1990;19:1010-1013.]
Steven M Setbst, MD* Mark Clark, MDt Philadelphia, Pennsylvania From the Emergency Department, Division of General Pediatrics, The Children's Hospital of Philadelphia;* and the Department of Emergency Medicine, Medical College of Pennsylvania,t Philadelphia. Received for publication July 21, 1989. Revision received November 20, 1989. Accepted for publication January 8, 1990. Presented at the 29th Annual Meeting of the Ambulatory Pediatric Association in Washington, DC, May 1989. Address for reprints: Steven M Selbst, MD, Emergency Department, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, Pennsylvania 19104.
INTRODUCTION Children and adults frequently seek care in emergency departments for the relief of pain. However, the management of acute pain in EDs has not been well studied. Others 1-3 have looked at analgesics given to children and adults who are hospital inpatients. Marks et al ~ noted that adults who are medical inpaticnts were often undertreated with narcotics, and m a n y patients continued to experience severe distress despite use of narcotic analgesics. Swafford and Allan z found that only 26 of 180 children admitted to an ICU received narcotics, and only two of 60 were given analgesics after surgery. Likewise, Beyer et al 3 noted that children were prescribed fewer narcotics than were adults following cardiac surgery, and the children were more likely to receive inaccurate and inadequate amounts of narcotics. More recently, Schechter et aD showed that hospitalized children and adults with the same diagnoses (hernias, appendectomies, burns, and femur fractures) were treated quite differently with regard to narcotic administration. They noted that adults received an average of 2.2 doses of narcotics per day, compared with 1.1 doses per day for children (P ~< .0001). We conducted this study to determine whether children and older patients (senior citizens) with acute, painful conditions received analgesics as often as other adults in two different EDs. We also wanted to determine whether children and senior citizens were sent h o m e from the ED with analgesics as often as other adults.
METHODS Records were reviewed for all patients who presented to the ED of the Children's Hospital of Philadelphia (CHOP) during a five-month period in 1987-1988 with a diagnosis of painful crises from sickle cell disease, lower-
19:9 September 1990
Annals of Emergency Medicine
1010/99
ANALGESICS
TABLE 1. Patients receiving pain medications
Sickle Cell Crises Total group
No.
%
No.
108/268
40
46/53
87
%
28*
20/27
LowerExtremity Fractures
Second- or Third-Degree Burns
No.
%
No.
%
31/84
37
31/131
24
74t
8/24
33
16/106
15*
12/139
31
15/23
65
11/21
52
0/2
--
Children
44/157
Adults
53/88
60
26/26
100
Senior citizens
11/23
48*
--
--
*P < .001. tp < .01. *P = NS.
extremity fractures (including fractures of hip, long bones, or metatarsals), or s e c o n d - or t h i r d - d e g r e e burns. Also, records were reviewed for all patients with these same diagnoses who presented to the ED of the Medical College of P e n n s y l v a n i a (MCP) during a similar seven-month period. These ED charts were assessed retrospectively for patient diagnosis, disposition, and use of narcotic and n o n n a r c o t i c analgesics while in the ED as well as discharge from the ED. Only patients with specific isolated injuries were included. Patients were excluded if they had multiple trauma or sickle cell crises complicated by fever, stroke, or other problems. Patients were also excluded if their injury occurred more than 12 hours before they presented to the ED. Patients less than 19 years old were classified as children. Patients 19 to 65 years old were considered adults, and those 66 or more years old were considered senior citizens. Analysis of data by X~ was performed. P < .05 was considered significant.
RESULTS T h e r e were 119 c h i l d r e n f r o m CHOP and 162 patients from MCP who were eligible for the study. Four patients from MCP were eliminated from analysis because their ages could not be determined, and two other patients were excluded because their charts could not be retrieved. Similarly, the charts of seven children from CHOP could not be retrieved, and these patients were excluded from the study. Thus, the charts of 112 children from CHOP 100/1011
and 156 patients from MCP were reviewed for the study; the study population comprised 157 children (59%), 88 adults (33%), and 23 senior citizens (9%). Of the children, 45 had been treated at MCP. Thirty-four percent of the evaluated patients were treated by pediatricians, 37% by emergency physicians, and 27% by more than one physician service (ie, with a surgical subspecialty consultant). Ages ranged from a few months to 97 years. Forty-nine percent of patients were male, and 83% were black. Patients required hospitalization because of their pain or injury in 15% of cases. Children were rarely admitted (0.6%), whereas senior citizens were often admitted (65%); 16% of adults 19 to 65 years old were admitted. The patients presented with sickle cell crises (53, 20%), lower-extremity fractures (84, 31%), or second- or third-degree burns (131, 49%). In the ED, only 40% of patients with these acutely painful conditions received analgesic medications (Table 1). C h i l d r e n were m u c h less likely than adults to receive analgesics (28% vs 60%)(P < .001), and senior citizens received these medications as often as younger adults. The analgesics given were almost always narcotics; only seven patients received n o n n a r c o t i c s alone. When narcotics were given, 12% of patients received less than the usual initial dose recommended by several standard texts. 5-7 Considering children specifically, those less than 2 years old were much less likely than older children to receive any medications for pain (17% vs 38%) {P < .01). Annals of Emergency Medicine
ED analgesic treatment for specific diagnoses is given (Table 1). For those with sickle cell crises, 87% of patients received analgesics. Every adult but only 74% of children with this condition received medication for pain (P = .01). There were no senior citizens with sickle cell crises. Only 37% of all patients with lowerextremity fractures received analgesics, and children and senior citizens were just as likely as adults to receive analgesics for pain from fractures. Less than one fourth of patients with burns received analgesics in the ED, and children were much less likely than adults to receive analgesics for pain from burns (t5% vs 65%) (P < .001). We attempted to see whether one group of physicians was more likely to give analgesics to children for pain in the ED and discovered that emergency physicians were s o m e w h a t more liberal with analgesics than were pediatricians. Emergency physicians gave 39% of the children pain medications compared with 23% of pediatricians (P = NS). Next, we considered the number of patients who received prescriptions or written advice about analgesics on discharge from the ED. Only 45% of all patients received written advice or prescriptions for analgesics when leaving the ED (Table 2). The total number of patients used for these calculations is smaller because hospitalized patients and those without clear written discharge instructions were excluded from the study. Thirty-five percent of children received prescriptions for analgesics or advice to take analgesics at home compared with 76% of adults (P < 19:9 September 1990
TABLE 2. Patients receiving pain medications at discharge for specific diagnoses
Sickle Cell Crises
LowerExtremity Fractures
Second- or Third-Degree Burns
No.
%
No.
%
No.
%
NO.
%
Total group
81/179
45
38/39
97
15/29
52
31/111
28
Children
47/133
35*
18/23
78
3/13
23t
24/97
25t
Adults
31/41
76
15/16
94
9/12
75
7/13
--
--
3/4
75
0/1
Senior citizens *p < ,-,,-,~ ,u~J
3/5
60:~
54
t.
t p < .05. ~P = NS.
.001). Senior citizens were just as likely as adults to be discharged with p r e s c r i p t i o n s or w r i t t e n advice to take analgesics at home. Sixty-two percent of patients who were discharged with medication received narcotics. Children and senior citizens w h o received m e d i c a t i o n s on discharge from the ED were just as likely as adults to receive narcotics. Again, children less t h a n 2 years old were m u c h less likely than older children to receive analgesic medication at discharge from the ED (20% vs 4 9 % ) ( P < .001). H o w o f t e n analgesics w e r e prescribed on discharge from the ED is given (Table 2). For those with sickle cell crises, 85% of patients were discharged with advice or prescriptions for analgesics. Children with sickle cell c r i s e s were just as l i k e l y as adults to receive these medications; however, for patients with lower-extremity fractures, only about half of the total group went h o m e with analgesics or written advice about their use. Children with lower-extremity fractures were m u c h less likely than adults or senior citizens to receive analgesics or written advice at the time of discharge. Similarly, for patients with secondor third-degree burns, only 28% went h o m e with pain medication. Again, children with burns were m u c h less likely than adults to receive analgesics at discharge from the ED (P < .O5). DISCUSSION This s t u d y shows that m o s t pat i e n t s w h o seek care in EDs for acute, painful conditions do not receive analgesics. W h e n medications 19:9 September 1990
are used in the ED, they are usually narcotics and usually appropriately dosed. This study was limited, however, because it was retrospective in design and because no a t t e m p t was made to determine h o w m u c h pain each patient was experiencing on presentation to the ED. However, the c o n d i t i o n s evaluated are generally considered to be painful. The adults and children had similar injuries except t h a t senior citizens had m o r e hip fractures than children and younger adults. Also, the n u m b e r of adult patients with sickle cell crises who m a y have been addicted to narcotics is not known; this may have influenced the a m o u n t of narcotics given to this group. Furthermore, other ins t i t u t i o n s m a y treat patients w i t h pain differently than the two sampled in this study. If they do not understand the pharm a c o l o g y of analgesics, e m e r g e n c y physicians and pediatricians may be r e l u c t a n t to prescribe these drugs. The management of pain is rarely included in residency training and is not often discussed in textbooks or journals. Also, m a n y physicians may fear that drug addiction could result from liberal use of narcotics in the ED. However, studies have s h o w n that iatrogenic drug addiction is extremely rare when narcotics are used appropriately in the acute setting. ~ Respiratory depression is another feared consequence of narcotic use. However, this is unlikely if appropriate doses are used, and the ED staff should be able to deal with such a complication. 9 Finally, in m a n y cases, emergency physicians are forced to concentrate on the more life-threatening issues of Annals of Emergency Medicine
resuscitation for trauma victims, and pain management is thus neglected. However, in our study, patients with life-threatening conditions were excluded, and still analgesics were usually withheld. Senior citizens received analgesics in the ED as often as younger adults. However, children were m u c h less likely than adults to receive analgesics for the same conditions. In particular, children less than 2 years old were less likely to receive these medications than older children. It is possible that these children required less analgesia than the adults. However, this discrepancy m a y instead be related to the clinician's lack of knowledge about these analgesics and h o w they relate to children; very few pediatric m e d i c a l t e x t b o o k s d i s c u s s pain management3 o Moreover, some physicians still harbor the misconception that children do not feel pain like adults do or that they will not remember it. Several studies have s h o w n t h a t young children, even neonates, experience pain. II 14 However, the behaviors they exhibit in response to painful stimuli m a y be more subtle than those of adults. Thus, a high index of suspicion is needed to identify children in pain. 15 Surprisingly, p e d i a t r i c i a n s gave less pain medication than emergency physicians, a l t h o u g h this was n o t s t a t i s t i c a l l y significant. T h i s m a y imply that pediatricians are less familiar than emergency physicians with the management of acute pain. It is possible that children received fewer analgesics than adults because they were less specific in their request for these medications. In some 10121101
cases, t h e c h i l d r e n p r o b a b l y did n o t r e q u e s t analgesics at all b e c a u s e t h e y f e a r e d a p a i n f u l i n j e c t i o n w o u l d result. ls-17 It s e e m s r e a s o n a b l e t h a t a v o c a l a d u l t s c r e a m i n g for m e d i c a tions for p a i n relief is m o r e l i k e l y to g e t t h e a t t e n t i o n a n d s p e c i f i c re* s p o n s e f r o m a p h y s i c i a n t h a n is a young child who may sit quietly, w h i m p e r i n g in pain. P e d i a t r i c i a n s and e m e r g e n c y physicians m u s t m a k e e v e r y effort to observe t h e facial and v o c a l e x p r e s s i o n s (including crying) of c h i l d r e n as w e l l as m u s c l e t o n e and o t h e r p h y s i o l o g i c signs of pain. T h e y m u s t t h e n prov i d e s u f f i c i e n t a n a l g e s i c s to r e l i e v e pain; t h e i n t r a m u s c u l a r r o u t e of administration s h o u l d be a v o i d e d w h e n e v e r possible.
tions to k e e p a b u r n c l e a n or a l i m b e l e v a t e d , m a n a g e m e n t of p a i n d i d n o t s e e m to w a r r a n t t h e s a m e l e v e l of a t t e n t i o n . A c u t e p a i n plays an i m p o r t a n t role for p e d i a t r i c i a n s and e m e r g e n c y physicians by aiding in the diagnosis or l o c a l i z a t i o n of an injury. H o w e v e r , n o p u r p o s e is s e r v e d by a l l o w i n g a p a t i e n t to e n d u r e t h i s pain for l o n g periods. Perhaps further education a b o u t p a i n m a n a g e m e n t is n e e d e d for e m e r g e n c y p h y s i c i a n s and p e d i a t r i cians. The authors thank Mr Murray Shames, Mr H o w a r d Furst, and Ms Valerie L McDaniel for their help with this study and Ms Pat Parkinson for assisting with this manuscript.
REFERENCES CONCLUSION P a t i e n t s i n o u r s t u d y r a r e l y received analgesic prescriptions or written advice about using these m e d i c a t i o n s w h e n t h e y left t h e ED. C h i l d r e n w e r e less l i k e l y t h a n adults to r e c e i v e a n a l g e s i c s at d i s c h a r g e . Admittedly, some patients may have received verbal instructions that w e r e n o t r e c o r d e d in t h e m e d i c a l record; h o w e v e r , t h e s e findings m a y indicate t h a t e m e r g e n c y p h y s i c i a n s and p e d i a t r i c i a n s did n o t c o n s i d e r p a i n m a n a g e m e n t at h o m e to be i m p o r tant. W h i l e t h e y often w r o t e i n s t r u c -
102/1013
i. Marks RM, Sachar EJ: Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973;78:173-181. 2. Swafford LI, Allan D: Pain relief in the pediatric patient. Med Clin North A m 1968~52: 131-136. 3. Beyer JE, DeGood DE, Ashley LC, et al: Patterns of post-operative analgesic use with adults and children following cardiac surgery. Pain 1983;17:71-81. 4. Schechter NL, Allen DA, Hanson K: Status of pediatric pain control: A comparison of hospital analgesic usage in children and adults. Pedi~ltrics 1986;77:11-15. 5. Paris PM, Weiss LD: Narcotic analgesics: The pure agonists, in Paris PM, Stewart RD (eds): &fin Management in Emergency Medi-
Annals of Emergency Medicine
cine. West Hartford, Connecticut, Appleton-
Lange, 1987. 6. Jaffe JH, Martin WR: Opioid analgesics and antagonists, in Goodman-Gilman A, Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics. New York, MacMillan, 1980, p 494-534. 7. Physician's Desk Reference, ed 43. Oradell, New Jersey, Medical Economics Company, i989. 8. Porter J, Jick H: Addiction rare in patients treated with narcotics. N Engl J Med 1980;302: 123. 9. Selbst SM: Managing pain in the pediatric emergency department. Pediatr Emerg C(~re 1989;5:56-63. 10. Rana SR: Pain A subject ignored (letter). Pediatrics 1987;79:309-310. I1. Porter FL, Miller RH, Marshall RE: Neonatal pain cries: Effect of circumcision on acoustic features and perceived urgency. Ch ild Dev 1986;57: 790-802. 12. Johnson CC, Strada ME: Acute pain response in infants: A multidimensional description. Pain 1986;24:373-382. 13. Pozanski EO: Children's reactions to pain: A psychiatrist's perspective. Clin Pediatr 1976; 15:1114-1119. 14. Anand KJS, Sippell WG, Aynsky-Green A: Randomized trial of fentanyl anesthesia in pre term babies undergoing surgery. Effects on tlk stress response. Lancet 1987;1:62 66. 15. Schechter NL: Pain: Acknowledging it, as sessing it, treating it. Contemp Pediatr 1987;4: 16~46. 16. Schecbter NL: Pain and pain control in chll dren. Curr Probl Pediatr 1985;15:1-67. 17. Fassler D, Wallace N: Children's fear of nee dles. Clin Pediatr 1982;2i:59-60.
19:9 September 1990
Analgesic Use in the Emergency Department The relief of pain is one of the most common reasons for seeking care in an emergency department. We conducted a retrospective chart review to see whether children received analgesic treatment similar to that of adults with the same acute, painful conditions. Charts of 112 pediatric patients from the Children's Hospital of Philadelphia ED and 156 patients from the Medical College of Pennsylvania ED were reviewed. Patient ages ranged from a few months to 97 years. All patients had acute pain due to sickle cell crises (20%), lower-extremity fractures (31%), or second-or third-degree burns (49%). Hospitalization was required in 15% of cases. In the ED, 60% of patients with painful conditions received no pain medications at aiI. When medications were given, they were usually narcotics. Children (aged I9 years or younger) were much less likely to receive pain medications than adults (P = .001). Those less than 2 years old received analgesics less often than older children (P < .01). Senior citizens (aged 65 years or older) received analgesics as often as other adults. On discharge from the ED, 55% of all patients had no pain medications prescribed; and children were less likely than adults to receive analgesics at discharge (P < .001). Pediatricians and emergency physicians are reluctant to use analgesics ,for children in pain. The data suggest that these physicians need additional education about management of acute pain. [Selbst SM, Clark M: Analgesic use in the emergency department. Ann Emerg Med September 1990;19:1010-1013.]
Steven M Setbst, MD* Mark Clark, MDt Philadelphia, Pennsylvania From the Emergency Department, Division of General Pediatrics, The Children's Hospital of Philadelphia;* and the Department of Emergency Medicine, Medical College of Pennsylvania,t Philadelphia. Received for publication July 21, 1989. Revision received November 20, 1989. Accepted for publication January 8, 1990. Presented at the 29th Annual Meeting of the Ambulatory Pediatric Association in Washington, DC, May 1989. Address for reprints: Steven M Selbst, MD, Emergency Department, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, Pennsylvania 19104.
INTRODUCTION Children and adults frequently seek care in emergency departments for the relief of pain. However, the management of acute pain in EDs has not been well studied. Others 1-3 have looked at analgesics given to children and adults who are hospital inpatients. Marks et al ~ noted that adults who are medical inpaticnts were often undertreated with narcotics, and m a n y patients continued to experience severe distress despite use of narcotic analgesics. Swafford and Allan z found that only 26 of 180 children admitted to an ICU received narcotics, and only two of 60 were given analgesics after surgery. Likewise, Beyer et al 3 noted that children were prescribed fewer narcotics than were adults following cardiac surgery, and the children were more likely to receive inaccurate and inadequate amounts of narcotics. More recently, Schechter et aD showed that hospitalized children and adults with the same diagnoses (hernias, appendectomies, burns, and femur fractures) were treated quite differently with regard to narcotic administration. They noted that adults received an average of 2.2 doses of narcotics per day, compared with 1.1 doses per day for children (P ~< .0001). We conducted this study to determine whether children and older patients (senior citizens) with acute, painful conditions received analgesics as often as other adults in two different EDs. We also wanted to determine whether children and senior citizens were sent h o m e from the ED with analgesics as often as other adults.
METHODS Records were reviewed for all patients who presented to the ED of the Children's Hospital of Philadelphia (CHOP) during a five-month period in 1987-1988 with a diagnosis of painful crises from sickle cell disease, lower-
19:9 September 1990
Annals of Emergency Medicine
1010/99
ANALGESICS
TABLE 1. Patients receiving pain medications
Sickle Cell Crises Total group
No.
%
No.
108/268
40
46/53
87
%
28*
20/27
LowerExtremity Fractures
Second- or Third-Degree Burns
No.
%
No.
%
31/84
37
31/131
24
74t
8/24
33
16/106
15*
12/139
31
15/23
65
11/21
52
0/2
--
Children
44/157
Adults
53/88
60
26/26
100
Senior citizens
11/23
48*
--
--
*P < .001. tp < .01. *P = NS.
extremity fractures (including fractures of hip, long bones, or metatarsals), or s e c o n d - or t h i r d - d e g r e e burns. Also, records were reviewed for all patients with these same diagnoses who presented to the ED of the Medical College of P e n n s y l v a n i a (MCP) during a similar seven-month period. These ED charts were assessed retrospectively for patient diagnosis, disposition, and use of narcotic and n o n n a r c o t i c analgesics while in the ED as well as discharge from the ED. Only patients with specific isolated injuries were included. Patients were excluded if they had multiple trauma or sickle cell crises complicated by fever, stroke, or other problems. Patients were also excluded if their injury occurred more than 12 hours before they presented to the ED. Patients less than 19 years old were classified as children. Patients 19 to 65 years old were considered adults, and those 66 or more years old were considered senior citizens. Analysis of data by X~ was performed. P < .05 was considered significant.
RESULTS T h e r e were 119 c h i l d r e n f r o m CHOP and 162 patients from MCP who were eligible for the study. Four patients from MCP were eliminated from analysis because their ages could not be determined, and two other patients were excluded because their charts could not be retrieved. Similarly, the charts of seven children from CHOP could not be retrieved, and these patients were excluded from the study. Thus, the charts of 112 children from CHOP 100/1011
and 156 patients from MCP were reviewed for the study; the study population comprised 157 children (59%), 88 adults (33%), and 23 senior citizens (9%). Of the children, 45 had been treated at MCP. Thirty-four percent of the evaluated patients were treated by pediatricians, 37% by emergency physicians, and 27% by more than one physician service (ie, with a surgical subspecialty consultant). Ages ranged from a few months to 97 years. Forty-nine percent of patients were male, and 83% were black. Patients required hospitalization because of their pain or injury in 15% of cases. Children were rarely admitted (0.6%), whereas senior citizens were often admitted (65%); 16% of adults 19 to 65 years old were admitted. The patients presented with sickle cell crises (53, 20%), lower-extremity fractures (84, 31%), or second- or third-degree burns (131, 49%). In the ED, only 40% of patients with these acutely painful conditions received analgesic medications (Table 1). C h i l d r e n were m u c h less likely than adults to receive analgesics (28% vs 60%)(P < .001), and senior citizens received these medications as often as younger adults. The analgesics given were almost always narcotics; only seven patients received n o n n a r c o t i c s alone. When narcotics were given, 12% of patients received less than the usual initial dose recommended by several standard texts. 5-7 Considering children specifically, those less than 2 years old were much less likely than older children to receive any medications for pain (17% vs 38%) {P < .01). Annals of Emergency Medicine
ED analgesic treatment for specific diagnoses is given (Table 1). For those with sickle cell crises, 87% of patients received analgesics. Every adult but only 74% of children with this condition received medication for pain (P = .01). There were no senior citizens with sickle cell crises. Only 37% of all patients with lowerextremity fractures received analgesics, and children and senior citizens were just as likely as adults to receive analgesics for pain from fractures. Less than one fourth of patients with burns received analgesics in the ED, and children were much less likely than adults to receive analgesics for pain from burns (t5% vs 65%) (P < .001). We attempted to see whether one group of physicians was more likely to give analgesics to children for pain in the ED and discovered that emergency physicians were s o m e w h a t more liberal with analgesics than were pediatricians. Emergency physicians gave 39% of the children pain medications compared with 23% of pediatricians (P = NS). Next, we considered the number of patients who received prescriptions or written advice about analgesics on discharge from the ED. Only 45% of all patients received written advice or prescriptions for analgesics when leaving the ED (Table 2). The total number of patients used for these calculations is smaller because hospitalized patients and those without clear written discharge instructions were excluded from the study. Thirty-five percent of children received prescriptions for analgesics or advice to take analgesics at home compared with 76% of adults (P < 19:9 September 1990
TABLE 2. Patients receiving pain medications at discharge for specific diagnoses
Sickle Cell Crises
LowerExtremity Fractures
Second- or Third-Degree Burns
No.
%
No.
%
No.
%
NO.
%
Total group
81/179
45
38/39
97
15/29
52
31/111
28
Children
47/133
35*
18/23
78
3/13
23t
24/97
25t
Adults
31/41
76
15/16
94
9/12
75
7/13
--
--
3/4
75
0/1
Senior citizens *p < ,-,,-,~ ,u~J
3/5
60:~
54
t.
t p < .05. ~P = NS.
.001). Senior citizens were just as likely as adults to be discharged with p r e s c r i p t i o n s or w r i t t e n advice to take analgesics at home. Sixty-two percent of patients who were discharged with medication received narcotics. Children and senior citizens w h o received m e d i c a t i o n s on discharge from the ED were just as likely as adults to receive narcotics. Again, children less t h a n 2 years old were m u c h less likely than older children to receive analgesic medication at discharge from the ED (20% vs 4 9 % ) ( P < .001). H o w o f t e n analgesics w e r e prescribed on discharge from the ED is given (Table 2). For those with sickle cell crises, 85% of patients were discharged with advice or prescriptions for analgesics. Children with sickle cell c r i s e s were just as l i k e l y as adults to receive these medications; however, for patients with lower-extremity fractures, only about half of the total group went h o m e with analgesics or written advice about their use. Children with lower-extremity fractures were m u c h less likely than adults or senior citizens to receive analgesics or written advice at the time of discharge. Similarly, for patients with secondor third-degree burns, only 28% went h o m e with pain medication. Again, children with burns were m u c h less likely than adults to receive analgesics at discharge from the ED (P < .O5). DISCUSSION This s t u d y shows that m o s t pat i e n t s w h o seek care in EDs for acute, painful conditions do not receive analgesics. W h e n medications 19:9 September 1990
are used in the ED, they are usually narcotics and usually appropriately dosed. This study was limited, however, because it was retrospective in design and because no a t t e m p t was made to determine h o w m u c h pain each patient was experiencing on presentation to the ED. However, the c o n d i t i o n s evaluated are generally considered to be painful. The adults and children had similar injuries except t h a t senior citizens had m o r e hip fractures than children and younger adults. Also, the n u m b e r of adult patients with sickle cell crises who m a y have been addicted to narcotics is not known; this may have influenced the a m o u n t of narcotics given to this group. Furthermore, other ins t i t u t i o n s m a y treat patients w i t h pain differently than the two sampled in this study. If they do not understand the pharm a c o l o g y of analgesics, e m e r g e n c y physicians and pediatricians may be r e l u c t a n t to prescribe these drugs. The management of pain is rarely included in residency training and is not often discussed in textbooks or journals. Also, m a n y physicians may fear that drug addiction could result from liberal use of narcotics in the ED. However, studies have s h o w n that iatrogenic drug addiction is extremely rare when narcotics are used appropriately in the acute setting. ~ Respiratory depression is another feared consequence of narcotic use. However, this is unlikely if appropriate doses are used, and the ED staff should be able to deal with such a complication. 9 Finally, in m a n y cases, emergency physicians are forced to concentrate on the more life-threatening issues of Annals of Emergency Medicine
resuscitation for trauma victims, and pain management is thus neglected. However, in our study, patients with life-threatening conditions were excluded, and still analgesics were usually withheld. Senior citizens received analgesics in the ED as often as younger adults. However, children were m u c h less likely than adults to receive analgesics for the same conditions. In particular, children less than 2 years old were less likely to receive these medications than older children. It is possible that these children required less analgesia than the adults. However, this discrepancy m a y instead be related to the clinician's lack of knowledge about these analgesics and h o w they relate to children; very few pediatric m e d i c a l t e x t b o o k s d i s c u s s pain management3 o Moreover, some physicians still harbor the misconception that children do not feel pain like adults do or that they will not remember it. Several studies have s h o w n t h a t young children, even neonates, experience pain. II 14 However, the behaviors they exhibit in response to painful stimuli m a y be more subtle than those of adults. Thus, a high index of suspicion is needed to identify children in pain. 15 Surprisingly, p e d i a t r i c i a n s gave less pain medication than emergency physicians, a l t h o u g h this was n o t s t a t i s t i c a l l y significant. T h i s m a y imply that pediatricians are less familiar than emergency physicians with the management of acute pain. It is possible that children received fewer analgesics than adults because they were less specific in their request for these medications. In some 10121101
cases, t h e c h i l d r e n p r o b a b l y did n o t r e q u e s t analgesics at all b e c a u s e t h e y f e a r e d a p a i n f u l i n j e c t i o n w o u l d result. ls-17 It s e e m s r e a s o n a b l e t h a t a v o c a l a d u l t s c r e a m i n g for m e d i c a tions for p a i n relief is m o r e l i k e l y to g e t t h e a t t e n t i o n a n d s p e c i f i c re* s p o n s e f r o m a p h y s i c i a n t h a n is a young child who may sit quietly, w h i m p e r i n g in pain. P e d i a t r i c i a n s and e m e r g e n c y physicians m u s t m a k e e v e r y effort to observe t h e facial and v o c a l e x p r e s s i o n s (including crying) of c h i l d r e n as w e l l as m u s c l e t o n e and o t h e r p h y s i o l o g i c signs of pain. T h e y m u s t t h e n prov i d e s u f f i c i e n t a n a l g e s i c s to r e l i e v e pain; t h e i n t r a m u s c u l a r r o u t e of administration s h o u l d be a v o i d e d w h e n e v e r possible.
tions to k e e p a b u r n c l e a n or a l i m b e l e v a t e d , m a n a g e m e n t of p a i n d i d n o t s e e m to w a r r a n t t h e s a m e l e v e l of a t t e n t i o n . A c u t e p a i n plays an i m p o r t a n t role for p e d i a t r i c i a n s and e m e r g e n c y physicians by aiding in the diagnosis or l o c a l i z a t i o n of an injury. H o w e v e r , n o p u r p o s e is s e r v e d by a l l o w i n g a p a t i e n t to e n d u r e t h i s pain for l o n g periods. Perhaps further education a b o u t p a i n m a n a g e m e n t is n e e d e d for e m e r g e n c y p h y s i c i a n s and p e d i a t r i cians. The authors thank Mr Murray Shames, Mr H o w a r d Furst, and Ms Valerie L McDaniel for their help with this study and Ms Pat Parkinson for assisting with this manuscript.
REFERENCES CONCLUSION P a t i e n t s i n o u r s t u d y r a r e l y received analgesic prescriptions or written advice about using these m e d i c a t i o n s w h e n t h e y left t h e ED. C h i l d r e n w e r e less l i k e l y t h a n adults to r e c e i v e a n a l g e s i c s at d i s c h a r g e . Admittedly, some patients may have received verbal instructions that w e r e n o t r e c o r d e d in t h e m e d i c a l record; h o w e v e r , t h e s e findings m a y indicate t h a t e m e r g e n c y p h y s i c i a n s and p e d i a t r i c i a n s did n o t c o n s i d e r p a i n m a n a g e m e n t at h o m e to be i m p o r tant. W h i l e t h e y often w r o t e i n s t r u c -
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i. Marks RM, Sachar EJ: Undertreatment of medical inpatients with narcotic analgesics. Ann Intern Med 1973;78:173-181. 2. Swafford LI, Allan D: Pain relief in the pediatric patient. Med Clin North A m 1968~52: 131-136. 3. Beyer JE, DeGood DE, Ashley LC, et al: Patterns of post-operative analgesic use with adults and children following cardiac surgery. Pain 1983;17:71-81. 4. Schechter NL, Allen DA, Hanson K: Status of pediatric pain control: A comparison of hospital analgesic usage in children and adults. Pedi~ltrics 1986;77:11-15. 5. Paris PM, Weiss LD: Narcotic analgesics: The pure agonists, in Paris PM, Stewart RD (eds): &fin Management in Emergency Medi-
Annals of Emergency Medicine
cine. West Hartford, Connecticut, Appleton-
Lange, 1987. 6. Jaffe JH, Martin WR: Opioid analgesics and antagonists, in Goodman-Gilman A, Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeutics. New York, MacMillan, 1980, p 494-534. 7. Physician's Desk Reference, ed 43. Oradell, New Jersey, Medical Economics Company, i989. 8. Porter J, Jick H: Addiction rare in patients treated with narcotics. N Engl J Med 1980;302: 123. 9. Selbst SM: Managing pain in the pediatric emergency department. Pediatr Emerg C(~re 1989;5:56-63. 10. Rana SR: Pain A subject ignored (letter). Pediatrics 1987;79:309-310. I1. Porter FL, Miller RH, Marshall RE: Neonatal pain cries: Effect of circumcision on acoustic features and perceived urgency. Ch ild Dev 1986;57: 790-802. 12. Johnson CC, Strada ME: Acute pain response in infants: A multidimensional description. Pain 1986;24:373-382. 13. Pozanski EO: Children's reactions to pain: A psychiatrist's perspective. Clin Pediatr 1976; 15:1114-1119. 14. Anand KJS, Sippell WG, Aynsky-Green A: Randomized trial of fentanyl anesthesia in pre term babies undergoing surgery. Effects on tlk stress response. Lancet 1987;1:62 66. 15. Schechter NL: Pain: Acknowledging it, as sessing it, treating it. Contemp Pediatr 1987;4: 16~46. 16. Schecbter NL: Pain and pain control in chll dren. Curr Probl Pediatr 1985;15:1-67. 17. Fassler D, Wallace N: Children's fear of nee dles. Clin Pediatr 1982;2i:59-60.
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