ORIGINAL ARTICLE
Prehospital Pain Management in Children With Traumatic Injuries Anna Rutkowska, PhD and Grażyna Skotnicka-Klonowicz, MD, PhD Summary: Damage that arises as a result of injuries is one of the most common causes of children presenting to hospital emergency departments. Objectives: The aim of the study was to assess the implementation of recommendations for prehospital pain management in injured children provided by various health care centers. Methods: A total of 7146 children aged 0 to 18 years because of injury were admitted to the Department of Paediatric Emergency Medicine in the Maria Konopnicka Memorial University Teaching Hospital No. 4 in Lodz within the period of 12 months. From this group, 1493 children received prehospital emergency care from various health care centers. Results: Health care centers provided prehospital aid to 21% of all children with injuries. Boys (60.3%) and children older than 5 years (80%) predominated among pediatric trauma cases. Prehospital emergency aid was most frequently administered to children by emergency medical services personnel (42.7%) and a primary health care physician (28.1%). Injuries of head (42.1%), neck (1.1%), chest (1.7%), abdomen (2.5%), upper (32.2%), and lower (19.9%) limbs as well as burns (5.3%) were diagnosed in pediatric patients. Indications for prehospital analgesia were found in 489 of 1493 patients (32.7%). Analgesia was administered to 159 children (32%), pain medication was not given to 223 children (46%), and in 107 cases (22%), there was a lack of information on that subject. Conclusions: Despite the training of medical staff, provision of analgesia for children with burns and traumatic injuries of the osteoarticular system is inadequate.
children in comparison to adults as a result omitted analgesic protection of children who have suffered trauma.1–3 In the light of current knowledge, it is known that each child feels pain irrespective of age; however, its intensity depends on many factors, such as sex, age, cognitive level, parents' behavior, previous pain experiences, environment, emotions, and causes.3–6 Pain management in the child with injury should comprise nonpharmacologic and pharmacologic interventions. The nonpharmacologic methods include application of ice packs and immobilization of fractures. If this procedure does not reduce pain, it is necessary to implement pharmacologic treatment. In case of burns, the prehospital analgesic treatment should be based on cooling the burned site and administration of analgesics.7,8 The literature data and the authors’ own observations suggest however, a number of errors in providing first aid to the child after injury in the prehospital setting, although the treatment of child’s trauma is a subject taught at medical schools in all fields of medical education and in Pediatric Advanced Life Support and Basic Trauma Life Support courses. These abnormalities most frequently pertain to withdrawal of pain treatment in children with burns or damages to the osteoarticular system.6–10 Injury is one of the most common reasons for children to report to hospital emergency departments. Hence, the aim of this study was to evaluate the use of analgesics in children after trauma by various health care centers in prehospital setting.
Key Words: pain, injuries, prehospital treatment (Pediatr Emer Care 2015;31: 317–320)
P
ain is an integral part of the body’s response to tissue injury, and its intensity is related to the extent, severity, and location of injury. The biological function of pain during the direct action of injury is protective and warns against overactivity to minimize the risk of further damage. On the other hand, the growing pain can lead to shock from pain, and therefore pain management is one of the most important therapies to be performed in the patient after trauma.1 Until recently, myths have been spread about the lack of pain sensation in neonates and infants and weaker pain experienced by
From the Department of Paediatric Emergency Medicine, Medical University of Lodz, Faculty of Health Sciences, Lodz, Poland. Disclosure: The authors declare no conflict of interest. Reprints: Anna Rutkowska, MD, PhD, Department of Paediatric Emergency Medicine, Maria Konopnicka Memorial University Teaching Hospital No. 4, 90-738 Lodz ul. Sporna 36/50, Lodz, Poland (e‐mail: [email protected]). The study was financed by: (1) The Medical University of Lodz within the programme for PhD students development no. 502-03/8-000-03/502-64-029. (2) The European Social Fund and the State Budget within the Action 2.6 of the Integrated Regional Development Operational Programme in relation to the implementation of the project entitled “Scholarships Supporting Innovative Research of PhD Students.” This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
METHODS The study involved 1493 children aged 0 to 18 years, who because of injury, were directed by various health care centers: emergency medical services personnel, primary health care physicians, and hospital emergency departments or admission rooms in other hospitals in the Lodz region as well as by school nurses to the Department of Paediatric Emergency Medicine in the Maria Konopnicka Memorial University Teaching Hospital No. 4 in Lodz in the period from May 1, 2009, to April 30, 2010. The study was prospective and did not include children with multiorgan injuries. After the injury, each child, which was transported to Emergency Department in the University Teaching Hospital No. 4, regardless of the health care centers who provide prehospital aid, was examined using the same methods. After the injury, each child was examined, and their charts, specially prepared by the study authors, were completed to achieve the aims of the study. The chart contained demographic data, information on the circumstances and causes of injury, time that passed from injury to the child's arrival at the hospital emergency department, season, location and type of injuries, details of the health care center providing first aid, and the method applied including the administration of analgesics. Each injured child's chart was entered into a database of Microsoft Excel programme and statistically analyzed for qualitative and quantitative traits.
RESULTS Of the 7146 children who reported with injury to the Department of Pediatric Emergency Medicine for 1 year, a group of the
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1493 (20.9%) was selected, which comprised the injured aged 0 to 18 years who received prehospital emergency aid from various health care centers. The remaining children arrived at the hospital straight from home or from the place of event. The characteristics of the study group are shown in Table 1. The predominance of boys over girls among children affected by traumatic injuries was statistically confirmed (P < 0.001). Eight hundred children, aged 5 to 14 years (53.6%), constituted the largest group of patients, followed by 381 children aged 0 to 4 years (25.5%) and 312 adolescents older than 14 years (20.9%). There were 265 children (17.7%) from the rural environment, 455 (30.5%) from small towns, and 773 (51.8%) from big cities. The injury usually occurred at home (27.7%), school (24.8%), the house yard (17.5%), or on the street (10.5%) (Fig. 1). There was a significant correlation between the location of the event and the age of the child (P < 0.001). It was found that in children younger than 4 years, the majority of injuries occurred at home (66.4%), and children older than 5 years dominated injuries which happened at school (65%). The cause of injury in the study children was ground-level fall (49% of the cases), a fall from a height (11.8%) and traffic accidents (8.6%) (Fig. 2). In the boys, the injuries significantly more often occurred as a result of beating, while burns (16%) dominated in the group of small children. Children aged 5 to 14 years were most frequently victims of road traffic accidents (9.4%), and the oldest children were injured because of beating (14.2%) (P < 0.001) The highest prevalence of traumatic injuries in children was reported in the spring and autumn (55%), and the highest attendance at hospital was in the afternoon (52.3%) and weekdays (78.6%). A total of 1144 of 1493 children (76.6%) were admitted the department during the first 4 hours after the event and 349 children (23.4%) in the later period. Prehospital medical aid was provided by various health care centers (Table 2). In the study group, children were injured in various parts of the body. Superficial head injuries (53.3%) prevailed in children after head trauma followed by a lower frequency of head wounds (24.3%) and brain concussion (20.3%) and the least frequency of skull fractures (2.1%). Among children with other injuries, blunt neck injuries and superficial injuries of the chest, abdomen, and spine were most often found. The forearm (42.7%) was the most common location of injury in the upper limb and the ankle (26.2%) in the lower limb. Significantly higher frequency of head injuries in children up to 4 years of age and injuries of the upper and lower limbs in children over 5 years (P > 0.001) was found. Among the study group of 1493 children, 491 (32.9%) required hospitalization, and 1002 children (67.1%) were treated in the outpatient setting.
FIGURE 1. The place of accident in the study group.
In the group of children who received first aid in various health care centers, indications for pain management were stated in 489 children (32.75%). Indication for analgesic treatment reported pain as the leading symptom by the child during examination in the pediatric emergency department, and usually, it was concerned children with fractures and burns. Of 489 children requiring emergency analgesia, only 159 children (32%) received analgesics, 223 children (46%) were left without analgesics, and in 107 patients (22%), there was no information on this subject in the medical records. Criterion for analgesic treatment children with injuries in the paediatric emergency department was the child's complaint of pain. The other children did not report pain or reported slight pain, which does not cause their discomfort. Of the 638 children who were given prehospital medical aid by emergency medical services teams, 207 children (32.4%) needed analgesia. Of these, only 104 children received analgesics (50.3%), and as many as 92 children (44.5%) were not provided with any pain medication, whereas in 11 cases, there were no data on pain treatment in the patients' run sheets after transfer to the university hospital. Among the children receiving medical aid provided by the school nurse (91 cases), the indications for analgesic treatment were found in 15 children (16.5%). Analgesia was used in 8 children (53.4%), 6 children (40%) did not receive any painkillers despite the indications, and a lack of information about using analgesics was stated in 1 child.
TABLE 1. Sex and Age in the Study Group Patients' Age No. patients Minimum Maximum Median Mean Standard deviation Asymmetry factor
318
Girls
Boys
592 (39.7%) 1 day 18 yr 10.1 yr 9.0 yr 5.33 1.25
901 (60.3%) 1 day 18 yr 12.2 yr 12.0 yr 5.24 1.60
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Total 1493 1 day 18 yr 11.4 yr 11.2 yr 5.28 1.45
FIGURE 2. The causes of injury in the study group. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Pediatric Emergency Care • Volume 31, Number 5, May 2015
Prehospital Pain Management in Children
TABLE 2. Various Health Care Centers in the Study Group Various Health Care Centers Emergency Medical Services Team Primary Health Care Physician Another Hospital School Nurse No. children
638 (42.7%)
420 (28.1%)
Of 420 children who during the prehospital period received medical care from a primary health care physician, 95 patients (22.6%) required pain treatment. Among these children, analgesics were administered only to 15 children (15.8%), 47 (49.5%) did not get any painkillers, and in 33 children (34.7%), there was no available information on this subject. Three hundred and forty-four patients received medical aid at another hospital in the Lodz region, among whom the indications for pain management interventions were stated in 172 children (50%). However, only 32 children (1.6%) in this group received analgesics. No attempt was made to control pain in 78 cases (45.4%), whereas in 62 patients (36%), there was no information available as to the treatment. The statistical analysis due to the small number of patients did not include the patients in whom first aid was provided by the school nurse. Although emergency medical services providers more frequently (50%) used pain medications as compared to other health care centres, they still abandoned administration of analgesics in more than 40% of children after traumatic injury. Lack of information on administration of analgesics in patients' transfer charts arouses some concern. This fact was reported significantly more frequently in the case of children referred for treatment by a primary health care physician (34.7%) and in patients transported from other hospitals (36%) (P < 0.001), whereas it was most rarely reported in the charts of children brought to the hospital emergency department by emergency medical services personnel (5.3%)—Pearson χ2 test = 87.33, P < 0.001; χ2 test = 96.30, P < 0.001 (Table 3). Children with fractures of the upper (92 cases, 41%) and lower limbs (21 cases, 9%) prevailed among the patients who did not receive analgesics.
DISCUSSION Correctly provided prehospital aid to the child after injury significantly affects disease prognosis. Therefore, current knowledge of first aid principles and of the emergency treatment of injuries is necessary for each health care provider and especially
344 (23%)
91 (6.1%)
for physicians, nurses, and paramedics working in the emergency medical services and primary health care systems. There are many training courses devoted to this issue. However, despite training, the prehospital emergency aid administered to pediatric patients after traumatic injury is far from ideal. The literature data indicate negligent care while providing emergency aid to the injured child. The medical oversight usually concerns the treatment of pain and the way of immobilization of transported children with osteoarticular injuries and burns.7,8,10–16 Observations of the American researchers reveal that pain assessment using pain scoring systems has been occasionally performed in children as compared to adult patients (4% vs. 67%), and analgesics have been administered 3 times more rarely in children than in adults.7,8 The structure of sex and age in the study group was similar to that in the investigations performed by other researchers.6,17–21 The observations concerning the place and causes of the events were also confirmed.21–26 The majority of children (72%) were provided with proper prehospital medical aid. Proper prehospital medical aid was considered according to the indications: the administration of analgesics, assumption immobilization correctly, supply of cutaneous injuries during transport to the hospital, and accurate compliance medical documentation. As a result from the present study, pain management was provided only in 159 children (32.5%), nearly half of the patients— 223 (45.6%)—despite indications to not receive any analgesics. These were the children with fractures of the upper (41%) and lower limbs (9.5%) as well as patients with burns (6.3%). The question arises why pain medication was not administered. Is this associated with a low level of knowledge in this field or with fear of possible side effects of analgesia? The American Academy of Pediatrics and the American Pain Society present the list of the main barriers to administration of analgesia in children who require emergency treatment, which include the myth that neonates and children experience less pain than adults, inability to assess pain, lack of knowledge of pain management, and fear of side effects of analgesia (especially respiratory depression).1,27–29
TABLE 3. The Use of Analgesic Therapy in the Study Group Health Care Centers Emergency Medical Services Team Pain Management No analgesic administration Analgesic administration Lack of information in the patient transfer chart Total Statistical analysis
School Nurse
Primary Health Care Physician
Another Hospital
No. Children
Structural Index, %
No. Children
Structural Index, %
No. Children
Structural Index, %
No. Children
Structural Index, %
92
44.44
6
40.00
47
49.47
78
45.35
104 11
50.24 5.31
8 1
53.33 6.67
15 33
15.79 34.74
32 62
18.60 36.05
207
100.00
172
100.00
15 100.00 95 100.00 χ2 test = 87.33 P < 0.001; χ2 test = 96.30 P < 0.001
Pearson
Note: School nurse was not included in the statistical analysis.
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The study carried out by physicians from the pediatric emergency department in Auckland, evaluating pain management in children by emergency medical services personnel, revealed that no child younger than 5 years, despite indications for using analgesics, received pain medication, and in a group of children older than 5 years, only half of them received analgesics. The ambulance personnel admitted that fear of inducing more pain by needle injection was the reason for abandoning pain management in children with injury.27 American researchers have also reported that one third of children with severe fractures did not receive analgesics. Moreover, they found that lack of analgesia administration was not related to specialization of an emergency physician providing emergency care (physician specializing in emergency medicine vs. physician specializing in pediatric emergency medicine). The survey also showed that analgesics were more often administered to adults than children.6,30 Similar observations were made with regard to pain management in children with burns by other researchers.10,31 Errors were committed by all health care center providers. Analgesia administration was most frequently provided (in about 50% of cases) by emergency medical services personnel and school nurses. However, all health care center providers abandoned the treatment in similar proportions (40%–49%). Incomplete medical records (no annotation in the documents or lack of drug dosing, however with verbal information about analgesia) were delivered by all health care centers. The least errors were found in the run sheets left by emergency medical services personnel (5.3%) and the greatest number in the records obtained from general practitioners (34.7%) and other hospitals (36%). This lack of diligence in completing medical records probably results from haste and lack of understanding of the importance of this information.
CONCLUSIONS The results of the study confirm the medical negligence in pain management in a large number of children suffering traumatic injuries and indicate the need for continuous training of health care providers in this area. REFERENCES 1. American Academy of Pediatrics, American Pain Society. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108:793–797. 2. Łapoć M, Ciechomski M, Mayzner-Zawadzka E. Opieka przedszpitalna u pacjentów z ciężkimi urazami. MedycynaIntensywnaiRatunkowa. 2003; tom 6, nr 1:29–34. 3. Krawczyński M, Szczepski O, Walczaka M. Textbook of Zarys Pediatrii. Warszawa PZWL: Rozdział 1 Rozwój dziecka; 1984:15–24. 4. Mayzner-Zawdzaka E, Błaszyk B, Serednicki W, et al. In: Ewa Mayzner –Zawadzka, Dariusz Kossan, Textbook of Postępowanie przeciwbólowe w urazach. Wybrane zalecenia postępowania w anestezjologii, Rozdział 12. Warszawa PZWL; 2008:97–107. 5. Joseph M H, Brill J, Zeltzer L K. Postępowanie przeciwbólowe w urazach u dzieci. Pediatria po dyplomie. Październik. 1999;3/5:62–73. 6. Swor R, McEachin CM, Seguin D, et al. Prehospital pain management in children suffering traumatic injury. Prehosp Emerg Care. 2005; 9,1:40–43. 7. Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical system. Pediatrics. 2004;114 No. 5:1348–1356. 8. Brown JC, Klein EJ, Lewis CW, et al. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42:197–205.
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9. Hennes H, Kim MK, Pirrallo RG. Prehospital pain management: a comparison of providers perceptions and practices. Prehosp Emerg Care. 2005;9,1:32–39. 10. Skotnicka-Klonowicz G, Grochocińska P, Trambowicz K. Leczenie bólu w okresie przedszpitalnym u oparzonych dzieci. ZdrowiePubliczne. 2012; 122:43–47. 11. Rawlins JM, Khan AA, Shenton AF, et al. Epidemiology and outcome analysis of 208 children with burns attending an emergency department. Pediatr Emerg Care. 2007;23:289–293. 12. Ashworth HL, Cubison TC, Gilbert PM. Treatment before transfer: the patient with burns. Emerg Med J. 2001;18:349–351. 13. Kennedy RM, Luhmann JD, Luhmann SJ. Emergency department management of pain and anxiety related to orthopedic fracture care; a guide to analgesic techniques and procedural sedation in children. Pediatr Drugs. 2004;6:11–31. 14. Singer AJ, Thode HC. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehabil. 2002;23: 361–365. 15. McLean SA, Maio RM, Domeier RM. The epidemiology of pain in the prehospital setting. Prehosp Emerg Care. 2002;6:402–405. 16. Kuziemska A, Skotnicka - Klonowicz G. Postępowanie przedszpitalne w urazach u dzieci ( doniesienia wstępne). Zdrow Publiczne. 2009;119: 395–398. 17. Ha G, Jeon MJ, Sakong J. Analysis of causes of injuries among children in Daegu, Korea. Korean J Pediatr. 2010;53:942–950. 18. Serinken M, Özen M. Characteristics of injuries due to traffic accidents in the pediatric age group. Ulus Travma Acil Cerrahi Derg. 2011;17:243–247. 19. Sharma M, Lahoti BK, Khandelwal G, et al. Epidemiological trends of pediatric trauma: a single-center study of 791 patients. J Indian Assoc Pediatr Surg. 2011;16:88–92. 20. Malinowska-Cieślik M, Czupryna A. Wypadki i urazy dzieci w wieku szkolnym w Polsce. ZdrowiePubliczne. 2002;112:505–510. 21. Oblacińska A, Mazur J, Woynarowska B. Urazowość młodzieży szkolnej w Polsce w świetle badań ankietowych. Medycynawiekurozwojowego. 1997; I. 1:27–33. 22. Nogalski A, Lubek T. Następstwa urazów u dzieci w województwie lubelskim—badania populacyjne. Polish J Emerg Med. 2008;tom 1 nr 3: 41–49. 23. Tandon T, Shaik M, Modi N. Paediatric trauma epidemiology in an urban scenario in India. J Orthop Surg. 2007;15:41–45. 24. Żyniewicz H, Marcinkowski JT. Wypadki i urazy u dzieci i młodzieży w świetle materiałów pogotowia ratunkowego w Poznaniu. Roczniki Pomorskiej Akademii Medycznej w Szczecinie. 2005;Tom LI (suppl 1. 51): 147–150. 25. Singh S, Smith GA, Fields SK, et al. Gymnastics-related injuries to children treated in emergency departments in the United States, 1990–2005. Pediatrics. 2008;121:954–960. 26. Burt CW, Overpeck MD. Emergency visits for sports-related injuries. Ann Emerg Med. 2001;37, 3:301–308. 27. Wathins N. Peadiatric prehospital analgesia in Auckland. Emerg Med Australas. 2006;18:51–56. 28. Rogovik AL. Prehospital use of analgesia at home or en route to the hospital in children with extremity injuries. Am J Emerg Med. 2007;25:400–405. 29. Probst BD. Factors affecting emergency department assessment and management of pain in children. Pediatr Emerg Care. 2005;21:298–305. 30. Cimpello LB, Khine H, Avner JR. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care. 2004;20:228–232. 31. Rawlins JM, Khan AA, Shenton AF, et al. Epidemiology and outcome analysis of 208 children with burns attending an emergency department. Pediatr Emerg Care. 2007;23:289–293.
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Prehospital Pain Management in Children With Traumatic Injuries Anna Rutkowska, PhD and Grażyna Skotnicka-Klonowicz, MD, PhD Summary: Damage that arises as a result of injuries is one of the most common causes of children presenting to hospital emergency departments. Objectives: The aim of the study was to assess the implementation of recommendations for prehospital pain management in injured children provided by various health care centers. Methods: A total of 7146 children aged 0 to 18 years because of injury were admitted to the Department of Paediatric Emergency Medicine in the Maria Konopnicka Memorial University Teaching Hospital No. 4 in Lodz within the period of 12 months. From this group, 1493 children received prehospital emergency care from various health care centers. Results: Health care centers provided prehospital aid to 21% of all children with injuries. Boys (60.3%) and children older than 5 years (80%) predominated among pediatric trauma cases. Prehospital emergency aid was most frequently administered to children by emergency medical services personnel (42.7%) and a primary health care physician (28.1%). Injuries of head (42.1%), neck (1.1%), chest (1.7%), abdomen (2.5%), upper (32.2%), and lower (19.9%) limbs as well as burns (5.3%) were diagnosed in pediatric patients. Indications for prehospital analgesia were found in 489 of 1493 patients (32.7%). Analgesia was administered to 159 children (32%), pain medication was not given to 223 children (46%), and in 107 cases (22%), there was a lack of information on that subject. Conclusions: Despite the training of medical staff, provision of analgesia for children with burns and traumatic injuries of the osteoarticular system is inadequate.
children in comparison to adults as a result omitted analgesic protection of children who have suffered trauma.1–3 In the light of current knowledge, it is known that each child feels pain irrespective of age; however, its intensity depends on many factors, such as sex, age, cognitive level, parents' behavior, previous pain experiences, environment, emotions, and causes.3–6 Pain management in the child with injury should comprise nonpharmacologic and pharmacologic interventions. The nonpharmacologic methods include application of ice packs and immobilization of fractures. If this procedure does not reduce pain, it is necessary to implement pharmacologic treatment. In case of burns, the prehospital analgesic treatment should be based on cooling the burned site and administration of analgesics.7,8 The literature data and the authors’ own observations suggest however, a number of errors in providing first aid to the child after injury in the prehospital setting, although the treatment of child’s trauma is a subject taught at medical schools in all fields of medical education and in Pediatric Advanced Life Support and Basic Trauma Life Support courses. These abnormalities most frequently pertain to withdrawal of pain treatment in children with burns or damages to the osteoarticular system.6–10 Injury is one of the most common reasons for children to report to hospital emergency departments. Hence, the aim of this study was to evaluate the use of analgesics in children after trauma by various health care centers in prehospital setting.
Key Words: pain, injuries, prehospital treatment (Pediatr Emer Care 2015;31: 317–320)
P
ain is an integral part of the body’s response to tissue injury, and its intensity is related to the extent, severity, and location of injury. The biological function of pain during the direct action of injury is protective and warns against overactivity to minimize the risk of further damage. On the other hand, the growing pain can lead to shock from pain, and therefore pain management is one of the most important therapies to be performed in the patient after trauma.1 Until recently, myths have been spread about the lack of pain sensation in neonates and infants and weaker pain experienced by
From the Department of Paediatric Emergency Medicine, Medical University of Lodz, Faculty of Health Sciences, Lodz, Poland. Disclosure: The authors declare no conflict of interest. Reprints: Anna Rutkowska, MD, PhD, Department of Paediatric Emergency Medicine, Maria Konopnicka Memorial University Teaching Hospital No. 4, 90-738 Lodz ul. Sporna 36/50, Lodz, Poland (e‐mail: [email protected]). The study was financed by: (1) The Medical University of Lodz within the programme for PhD students development no. 502-03/8-000-03/502-64-029. (2) The European Social Fund and the State Budget within the Action 2.6 of the Integrated Regional Development Operational Programme in relation to the implementation of the project entitled “Scholarships Supporting Innovative Research of PhD Students.” This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161
METHODS The study involved 1493 children aged 0 to 18 years, who because of injury, were directed by various health care centers: emergency medical services personnel, primary health care physicians, and hospital emergency departments or admission rooms in other hospitals in the Lodz region as well as by school nurses to the Department of Paediatric Emergency Medicine in the Maria Konopnicka Memorial University Teaching Hospital No. 4 in Lodz in the period from May 1, 2009, to April 30, 2010. The study was prospective and did not include children with multiorgan injuries. After the injury, each child, which was transported to Emergency Department in the University Teaching Hospital No. 4, regardless of the health care centers who provide prehospital aid, was examined using the same methods. After the injury, each child was examined, and their charts, specially prepared by the study authors, were completed to achieve the aims of the study. The chart contained demographic data, information on the circumstances and causes of injury, time that passed from injury to the child's arrival at the hospital emergency department, season, location and type of injuries, details of the health care center providing first aid, and the method applied including the administration of analgesics. Each injured child's chart was entered into a database of Microsoft Excel programme and statistically analyzed for qualitative and quantitative traits.
RESULTS Of the 7146 children who reported with injury to the Department of Pediatric Emergency Medicine for 1 year, a group of the
Pediatric Emergency Care • Volume 31, Number 5, May 2015
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1493 (20.9%) was selected, which comprised the injured aged 0 to 18 years who received prehospital emergency aid from various health care centers. The remaining children arrived at the hospital straight from home or from the place of event. The characteristics of the study group are shown in Table 1. The predominance of boys over girls among children affected by traumatic injuries was statistically confirmed (P < 0.001). Eight hundred children, aged 5 to 14 years (53.6%), constituted the largest group of patients, followed by 381 children aged 0 to 4 years (25.5%) and 312 adolescents older than 14 years (20.9%). There were 265 children (17.7%) from the rural environment, 455 (30.5%) from small towns, and 773 (51.8%) from big cities. The injury usually occurred at home (27.7%), school (24.8%), the house yard (17.5%), or on the street (10.5%) (Fig. 1). There was a significant correlation between the location of the event and the age of the child (P < 0.001). It was found that in children younger than 4 years, the majority of injuries occurred at home (66.4%), and children older than 5 years dominated injuries which happened at school (65%). The cause of injury in the study children was ground-level fall (49% of the cases), a fall from a height (11.8%) and traffic accidents (8.6%) (Fig. 2). In the boys, the injuries significantly more often occurred as a result of beating, while burns (16%) dominated in the group of small children. Children aged 5 to 14 years were most frequently victims of road traffic accidents (9.4%), and the oldest children were injured because of beating (14.2%) (P < 0.001) The highest prevalence of traumatic injuries in children was reported in the spring and autumn (55%), and the highest attendance at hospital was in the afternoon (52.3%) and weekdays (78.6%). A total of 1144 of 1493 children (76.6%) were admitted the department during the first 4 hours after the event and 349 children (23.4%) in the later period. Prehospital medical aid was provided by various health care centers (Table 2). In the study group, children were injured in various parts of the body. Superficial head injuries (53.3%) prevailed in children after head trauma followed by a lower frequency of head wounds (24.3%) and brain concussion (20.3%) and the least frequency of skull fractures (2.1%). Among children with other injuries, blunt neck injuries and superficial injuries of the chest, abdomen, and spine were most often found. The forearm (42.7%) was the most common location of injury in the upper limb and the ankle (26.2%) in the lower limb. Significantly higher frequency of head injuries in children up to 4 years of age and injuries of the upper and lower limbs in children over 5 years (P > 0.001) was found. Among the study group of 1493 children, 491 (32.9%) required hospitalization, and 1002 children (67.1%) were treated in the outpatient setting.
FIGURE 1. The place of accident in the study group.
In the group of children who received first aid in various health care centers, indications for pain management were stated in 489 children (32.75%). Indication for analgesic treatment reported pain as the leading symptom by the child during examination in the pediatric emergency department, and usually, it was concerned children with fractures and burns. Of 489 children requiring emergency analgesia, only 159 children (32%) received analgesics, 223 children (46%) were left without analgesics, and in 107 patients (22%), there was no information on this subject in the medical records. Criterion for analgesic treatment children with injuries in the paediatric emergency department was the child's complaint of pain. The other children did not report pain or reported slight pain, which does not cause their discomfort. Of the 638 children who were given prehospital medical aid by emergency medical services teams, 207 children (32.4%) needed analgesia. Of these, only 104 children received analgesics (50.3%), and as many as 92 children (44.5%) were not provided with any pain medication, whereas in 11 cases, there were no data on pain treatment in the patients' run sheets after transfer to the university hospital. Among the children receiving medical aid provided by the school nurse (91 cases), the indications for analgesic treatment were found in 15 children (16.5%). Analgesia was used in 8 children (53.4%), 6 children (40%) did not receive any painkillers despite the indications, and a lack of information about using analgesics was stated in 1 child.
TABLE 1. Sex and Age in the Study Group Patients' Age No. patients Minimum Maximum Median Mean Standard deviation Asymmetry factor
318
Girls
Boys
592 (39.7%) 1 day 18 yr 10.1 yr 9.0 yr 5.33 1.25
901 (60.3%) 1 day 18 yr 12.2 yr 12.0 yr 5.24 1.60
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Total 1493 1 day 18 yr 11.4 yr 11.2 yr 5.28 1.45
FIGURE 2. The causes of injury in the study group. © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Pediatric Emergency Care • Volume 31, Number 5, May 2015
Prehospital Pain Management in Children
TABLE 2. Various Health Care Centers in the Study Group Various Health Care Centers Emergency Medical Services Team Primary Health Care Physician Another Hospital School Nurse No. children
638 (42.7%)
420 (28.1%)
Of 420 children who during the prehospital period received medical care from a primary health care physician, 95 patients (22.6%) required pain treatment. Among these children, analgesics were administered only to 15 children (15.8%), 47 (49.5%) did not get any painkillers, and in 33 children (34.7%), there was no available information on this subject. Three hundred and forty-four patients received medical aid at another hospital in the Lodz region, among whom the indications for pain management interventions were stated in 172 children (50%). However, only 32 children (1.6%) in this group received analgesics. No attempt was made to control pain in 78 cases (45.4%), whereas in 62 patients (36%), there was no information available as to the treatment. The statistical analysis due to the small number of patients did not include the patients in whom first aid was provided by the school nurse. Although emergency medical services providers more frequently (50%) used pain medications as compared to other health care centres, they still abandoned administration of analgesics in more than 40% of children after traumatic injury. Lack of information on administration of analgesics in patients' transfer charts arouses some concern. This fact was reported significantly more frequently in the case of children referred for treatment by a primary health care physician (34.7%) and in patients transported from other hospitals (36%) (P < 0.001), whereas it was most rarely reported in the charts of children brought to the hospital emergency department by emergency medical services personnel (5.3%)—Pearson χ2 test = 87.33, P < 0.001; χ2 test = 96.30, P < 0.001 (Table 3). Children with fractures of the upper (92 cases, 41%) and lower limbs (21 cases, 9%) prevailed among the patients who did not receive analgesics.
DISCUSSION Correctly provided prehospital aid to the child after injury significantly affects disease prognosis. Therefore, current knowledge of first aid principles and of the emergency treatment of injuries is necessary for each health care provider and especially
344 (23%)
91 (6.1%)
for physicians, nurses, and paramedics working in the emergency medical services and primary health care systems. There are many training courses devoted to this issue. However, despite training, the prehospital emergency aid administered to pediatric patients after traumatic injury is far from ideal. The literature data indicate negligent care while providing emergency aid to the injured child. The medical oversight usually concerns the treatment of pain and the way of immobilization of transported children with osteoarticular injuries and burns.7,8,10–16 Observations of the American researchers reveal that pain assessment using pain scoring systems has been occasionally performed in children as compared to adult patients (4% vs. 67%), and analgesics have been administered 3 times more rarely in children than in adults.7,8 The structure of sex and age in the study group was similar to that in the investigations performed by other researchers.6,17–21 The observations concerning the place and causes of the events were also confirmed.21–26 The majority of children (72%) were provided with proper prehospital medical aid. Proper prehospital medical aid was considered according to the indications: the administration of analgesics, assumption immobilization correctly, supply of cutaneous injuries during transport to the hospital, and accurate compliance medical documentation. As a result from the present study, pain management was provided only in 159 children (32.5%), nearly half of the patients— 223 (45.6%)—despite indications to not receive any analgesics. These were the children with fractures of the upper (41%) and lower limbs (9.5%) as well as patients with burns (6.3%). The question arises why pain medication was not administered. Is this associated with a low level of knowledge in this field or with fear of possible side effects of analgesia? The American Academy of Pediatrics and the American Pain Society present the list of the main barriers to administration of analgesia in children who require emergency treatment, which include the myth that neonates and children experience less pain than adults, inability to assess pain, lack of knowledge of pain management, and fear of side effects of analgesia (especially respiratory depression).1,27–29
TABLE 3. The Use of Analgesic Therapy in the Study Group Health Care Centers Emergency Medical Services Team Pain Management No analgesic administration Analgesic administration Lack of information in the patient transfer chart Total Statistical analysis
School Nurse
Primary Health Care Physician
Another Hospital
No. Children
Structural Index, %
No. Children
Structural Index, %
No. Children
Structural Index, %
No. Children
Structural Index, %
92
44.44
6
40.00
47
49.47
78
45.35
104 11
50.24 5.31
8 1
53.33 6.67
15 33
15.79 34.74
32 62
18.60 36.05
207
100.00
172
100.00
15 100.00 95 100.00 χ2 test = 87.33 P < 0.001; χ2 test = 96.30 P < 0.001
Pearson
Note: School nurse was not included in the statistical analysis.
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319
Pediatric Emergency Care • Volume 31, Number 5, May 2015
Rutkowska and Skotnicka-Klonowicz
The study carried out by physicians from the pediatric emergency department in Auckland, evaluating pain management in children by emergency medical services personnel, revealed that no child younger than 5 years, despite indications for using analgesics, received pain medication, and in a group of children older than 5 years, only half of them received analgesics. The ambulance personnel admitted that fear of inducing more pain by needle injection was the reason for abandoning pain management in children with injury.27 American researchers have also reported that one third of children with severe fractures did not receive analgesics. Moreover, they found that lack of analgesia administration was not related to specialization of an emergency physician providing emergency care (physician specializing in emergency medicine vs. physician specializing in pediatric emergency medicine). The survey also showed that analgesics were more often administered to adults than children.6,30 Similar observations were made with regard to pain management in children with burns by other researchers.10,31 Errors were committed by all health care center providers. Analgesia administration was most frequently provided (in about 50% of cases) by emergency medical services personnel and school nurses. However, all health care center providers abandoned the treatment in similar proportions (40%–49%). Incomplete medical records (no annotation in the documents or lack of drug dosing, however with verbal information about analgesia) were delivered by all health care centers. The least errors were found in the run sheets left by emergency medical services personnel (5.3%) and the greatest number in the records obtained from general practitioners (34.7%) and other hospitals (36%). This lack of diligence in completing medical records probably results from haste and lack of understanding of the importance of this information.
CONCLUSIONS The results of the study confirm the medical negligence in pain management in a large number of children suffering traumatic injuries and indicate the need for continuous training of health care providers in this area. REFERENCES 1. American Academy of Pediatrics, American Pain Society. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108:793–797. 2. Łapoć M, Ciechomski M, Mayzner-Zawadzka E. Opieka przedszpitalna u pacjentów z ciężkimi urazami. MedycynaIntensywnaiRatunkowa. 2003; tom 6, nr 1:29–34. 3. Krawczyński M, Szczepski O, Walczaka M. Textbook of Zarys Pediatrii. Warszawa PZWL: Rozdział 1 Rozwój dziecka; 1984:15–24. 4. Mayzner-Zawdzaka E, Błaszyk B, Serednicki W, et al. In: Ewa Mayzner –Zawadzka, Dariusz Kossan, Textbook of Postępowanie przeciwbólowe w urazach. Wybrane zalecenia postępowania w anestezjologii, Rozdział 12. Warszawa PZWL; 2008:97–107. 5. Joseph M H, Brill J, Zeltzer L K. Postępowanie przeciwbólowe w urazach u dzieci. Pediatria po dyplomie. Październik. 1999;3/5:62–73. 6. Swor R, McEachin CM, Seguin D, et al. Prehospital pain management in children suffering traumatic injury. Prehosp Emerg Care. 2005; 9,1:40–43. 7. Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical system. Pediatrics. 2004;114 No. 5:1348–1356. 8. Brown JC, Klein EJ, Lewis CW, et al. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42:197–205.
320
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9. Hennes H, Kim MK, Pirrallo RG. Prehospital pain management: a comparison of providers perceptions and practices. Prehosp Emerg Care. 2005;9,1:32–39. 10. Skotnicka-Klonowicz G, Grochocińska P, Trambowicz K. Leczenie bólu w okresie przedszpitalnym u oparzonych dzieci. ZdrowiePubliczne. 2012; 122:43–47. 11. Rawlins JM, Khan AA, Shenton AF, et al. Epidemiology and outcome analysis of 208 children with burns attending an emergency department. Pediatr Emerg Care. 2007;23:289–293. 12. Ashworth HL, Cubison TC, Gilbert PM. Treatment before transfer: the patient with burns. Emerg Med J. 2001;18:349–351. 13. Kennedy RM, Luhmann JD, Luhmann SJ. Emergency department management of pain and anxiety related to orthopedic fracture care; a guide to analgesic techniques and procedural sedation in children. Pediatr Drugs. 2004;6:11–31. 14. Singer AJ, Thode HC. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care Rehabil. 2002;23: 361–365. 15. McLean SA, Maio RM, Domeier RM. The epidemiology of pain in the prehospital setting. Prehosp Emerg Care. 2002;6:402–405. 16. Kuziemska A, Skotnicka - Klonowicz G. Postępowanie przedszpitalne w urazach u dzieci ( doniesienia wstępne). Zdrow Publiczne. 2009;119: 395–398. 17. Ha G, Jeon MJ, Sakong J. Analysis of causes of injuries among children in Daegu, Korea. Korean J Pediatr. 2010;53:942–950. 18. Serinken M, Özen M. Characteristics of injuries due to traffic accidents in the pediatric age group. Ulus Travma Acil Cerrahi Derg. 2011;17:243–247. 19. Sharma M, Lahoti BK, Khandelwal G, et al. Epidemiological trends of pediatric trauma: a single-center study of 791 patients. J Indian Assoc Pediatr Surg. 2011;16:88–92. 20. Malinowska-Cieślik M, Czupryna A. Wypadki i urazy dzieci w wieku szkolnym w Polsce. ZdrowiePubliczne. 2002;112:505–510. 21. Oblacińska A, Mazur J, Woynarowska B. Urazowość młodzieży szkolnej w Polsce w świetle badań ankietowych. Medycynawiekurozwojowego. 1997; I. 1:27–33. 22. Nogalski A, Lubek T. Następstwa urazów u dzieci w województwie lubelskim—badania populacyjne. Polish J Emerg Med. 2008;tom 1 nr 3: 41–49. 23. Tandon T, Shaik M, Modi N. Paediatric trauma epidemiology in an urban scenario in India. J Orthop Surg. 2007;15:41–45. 24. Żyniewicz H, Marcinkowski JT. Wypadki i urazy u dzieci i młodzieży w świetle materiałów pogotowia ratunkowego w Poznaniu. Roczniki Pomorskiej Akademii Medycznej w Szczecinie. 2005;Tom LI (suppl 1. 51): 147–150. 25. Singh S, Smith GA, Fields SK, et al. Gymnastics-related injuries to children treated in emergency departments in the United States, 1990–2005. Pediatrics. 2008;121:954–960. 26. Burt CW, Overpeck MD. Emergency visits for sports-related injuries. Ann Emerg Med. 2001;37, 3:301–308. 27. Wathins N. Peadiatric prehospital analgesia in Auckland. Emerg Med Australas. 2006;18:51–56. 28. Rogovik AL. Prehospital use of analgesia at home or en route to the hospital in children with extremity injuries. Am J Emerg Med. 2007;25:400–405. 29. Probst BD. Factors affecting emergency department assessment and management of pain in children. Pediatr Emerg Care. 2005;21:298–305. 30. Cimpello LB, Khine H, Avner JR. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care. 2004;20:228–232. 31. Rawlins JM, Khan AA, Shenton AF, et al. Epidemiology and outcome analysis of 208 children with burns attending an emergency department. Pediatr Emerg Care. 2007;23:289–293.
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