Prehospital use of analgesics at home or en route to the hospital in children with extremity injuries

Abstract

Purpose

The purpose of the study was to document prehospital analgesia (PA) for children with extremity injuries at home or en route to the hospital, as assessed by research personnel at the pediatric emergency department.

Methods

Two parallel groups of patients with fractures or soft-tissue injuries (STIs) were chosen for this prospective observational study. Patients 3 to 18 years of age with a limb or clavicle injury were enrolled. Parents or children were interviewed, pain assessed, and data from the emergency department charts collected.

Results

A total of 310 patients were recruited; their mean age was 10.2 years, and 62% had fractures. The median pain score was 4.0, with no significant difference between fractures and STI. Of the patients, 78% had PA, 73% received first aid (icing, immobilization), and 37% had medication, mostly acetaminophen and ibuprofen. Children with fractures and STI received PA at a similar rate; however, the time to first aid was shorter in those with fractures.

Conclusion

Most patients with moderate or severe pain did not receive prehospital pain medication. Parental education and moderate over-the-counter analgesics are needed for better pain relief.

Introduction

Pain is one of the most common symptoms in patients presenting to the emergency department (ED) [1] and is perceived as a difficult issue for the pediatric ED care providers [2], [3] despite evidence that a child's experience of pain is as severe as that of an adult [4], [5].

Current knowledge on prehospital analgesia (PA) for children at home or en route to the hospital is limited. Previous reports documented inadequate prehospital use of analgesia by emergency medical services (EMS) personnel [6], [7] in children with injuries, especially among the younger age group [8], [9].

Underestimation of patients' needs [1], uncertainty as to routes of administration, pediatric drug dosing, and perceived discomfort with the care of an injured child are all barriers to administration of analgesia in children [6]. In its recent emergency practice guidelines, the American Academy of Pediatrics recommended eliminating any barriers preventing appropriate and timely administration of analgesia to the child who requires emergency treatment and taking every opportunity to use available methods of pain control [10]. The National Association of EMS Physicians [11] recommends including both nonpharmacologic and pharmacologic interventions in prehospital pain management protocols, with first aid measures such as application of ice packs, immobilization of fractures, or elevation of extremities to be provided regardless of whether or not medications are used.

We are unaware of any previous studies providing insight into parental analgesia except for one survey of parents/guardians of children with head injuries or limb problems, including burns, conducted at an accident and emergency (A&E) department in the UK by Spedding et al [12]. They found that 74% of children did not receive pain medication before attendance at the A&E department. First aid nonpharmacologic pain relief by parents was not documented.

Studies conducted in EMS adult patients have also shown that patients with suspected fractures rarely receive PA [13], [14].

The objective of this study was to document and assess PA, both pharmacologic and nonpharmacologic, at home or en route to the hospital for limb and clavicle injuries in patients admitted to the pediatric ED. We hypothesized that children with fractures receive analgesia more often and sooner than patients with soft-tissue injuries (STI).