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CLINICAL Pediatric Emergency Medicine
CLINICAL Pediatric Emergency Medicine

CLINICAL

Pediatric Emergency Medicine

Editor

Steven E. Krug, MD,

FAAP

Feinberg School of Medicine, Northwestern University, Children’s Memorial Hospital, Chicago, IL

W.B. Saunders
W.B. Saunders

www.clinpedemergencymed.org

Vol 11, No 1

March 2010

Advances In Pediatric Trauma

Harold K. Simon, MD, MBA Guest Editor

In Pediatric Trauma Harold K. Simon, MD, MBA Guest Editor 1 4 10 18 22 .

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GUEST EDITOR’S PREFACE Pediatric Trauma: A Roadmap for Evidence-Based, Patient-Centered Coordination and Care

 

Harold K. Simon

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Golden Hour or Golden Opportunity: Early Management of Pediatric Trauma

 

Wendalyn K. Little

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Prehospital Management of Pediatric Trauma

 

Manish I. Shah

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Do Routine Laboratory Tests Add to the Care of the Pediatric Trauma Patient?

 

Jeffrey F. Linzer Sr

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Radiographic Evaluation of the Pediatric Trauma Patient and the Risk for Ionization Radiation Exposure

 

Ricardo R. Jiménez

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Analgesia for the Pediatric Trauma Patient: Primum Non Nocere?

 

Michael Greenwald

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When There Are no Inpatient Beds: Pediatric Intensive Care Level Management of Trauma Patients in the Emergency Department

 

Toni Petrillo-Albarano and Wendalyn K. Little

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Pediatric Patients in the Adult Trauma Bay—Comfort Level and Challenges

 

Kimberly P. Stone and George A. Woodward

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Mental Health Consequences of Trauma: The Unseen Scars

Michael Finn Ziegler

GUEST EDITOR'S PREFACE

Pediatric Trauma: A Roadmap for Evidence- Based, Patient-Centered Coordination and Care

By Harold K. Simon, MD, MBA

F or children younger than 14 years, there has been a dramatic and steady decline over the past

2 decades in injury-related mortality from 9427 deaths in 1986 (age-adjusted rate of 18.04/100 000) to 6530 in 2006 (age-adjusted rate of 10.59/ 100 000). 1 Many factors contribute to this improve- ment including injury prevention strategies as well as treatment and aftercare of trauma patients. Although tremendous strides have been made, injury remains a leading cause of morbidity and mortality in the United States and is especially concerning within the pediatric population where trauma can rob years of happiness and productivity. This issue of Clinical Pediatric Emergency Medicine focuses on the complete spectrum of pediatric trauma care, beginning with the initial golden hour, emergency medical services care at the scene, through critical care management. It incor- porates perspectives from pediatric emergency medicine physicians, emergency medical services providers, and critical care physicians. It will address present state of care, improvement strate- gies, and potential areas that can help us not only decrease mortality but do so in a cost-effective manner cognizant of facility and manpower re- source limitations. Unlike many previous antholo-

Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA.

gies on the subject, it will also take into perspective a more patient-centered approach to what can be done with new and emerging technologies, taking into account long-term implications when consid- ering what interventions are most beneficial to the patient in the immediate care situation. It will look at questions such as the risk vs benefits of computed tomographic scanning in light of radia- tion exposure. This issue will address topics such as coordination of care between subspecialties, transi- tions of care, and care of pediatric trauma patients in adult-based centers. It will, however, go beyond the traditional bounds and will touch on the more holistic approach to care that can and should be part of our broader perspective on pediatric trauma management. This will include sections on pain control as well as posttraumatic stress disorder recognition and prevention. Trauma care has emerged from its infancy in the latter part of the 21st century as a focus of modern medicine. Military experiences have helped push the envelope of trauma care and continues to help us mold our perspectives, knowledge, and treatment of trauma. 2,3 Trauma centers have been proven to have a positive impact on patient management, ultimately leading to decreased mortality. 4 Pediatric trauma care has, however, as is the case in most areas of pediatric medicine, taken a backseat to much of the initial focus that has been adult patient based. It was not until the development of the

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VOL. 11, NO. 1 PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON

Emergency Medical Services for Children program in 1984 and the Institute of Medicine report on Emergency Medical Services for Children that pediatric trauma care began to separate itself out as a functionally distinct discipline. 5,6 Evidence has mounted over the years that regiona- lized centers with pediatric equipment, personnel, and expertise have contributed to the overall improvement in pediatric trauma management. 7-9 In addition, coordinated aftercare in centers with pediatric sur- geons and pediatric critical care physicians has improved outcomes. Differences in operative vs supportive treatment of the pediatric patient as compared with the adult trauma patient, especially for blunt abdominal trauma, and comfort levels and expertise with the pediatric patient may contribute to these effects. 10 Consensus opinion and present stan- dards for field triage of pediatric trauma patients support the direction of those children meeting trauma criteria to a pediatric capable trauma center. 11 Many communities do not have the volume of patients or resources required to support designated pediatric trauma centers. Facilities within communi- ties that do have this volume are often stretched beyond their functional capacity given the prevalence of emergency department overcrowding and the use of emergency departments as the safety net for medical care for many underserved populations. 12,13 These factors, along with the shear cost of keeping trauma centers available 24/7 in communities that may not have the required resources, make it even more important to develop trauma centers within well- coordinated regional systems to best transport, stabi- lize, and definitively care for critically injured chil- dren. 11,14 However, today, fewer than 200 pediatric trauma centers exist in the United States; and more than 28% of children younger than 15 years are more than 1 hour from such centers by ground or by air transport. This disparity is even greater in rural areas, where 77% of children are more than 1 hour from such centers. 15 Given the critical importance of stabilization within the golden opportunityfor care, we have a long way to go in coordinating such care and establish- ing centers capable of providing optimal management to this vulnerable population. This points to a need to expand access to pediatric trauma care for greater numbers of children and to continue to grow and enhance the networks available. Those centers that do exist need to fully coordinate care over large catchment areas with the necessary support systems and transfer protocols to best serve the children throughout their regions. These items will be among those addressed in this series of articles and are some of the most challenging issues faced as we seek to continue to expand and enhance pediatric trauma networks.

Even when we are fortunate enough to have an abundance of resources or tertiary care pediatric facilities in a region, we must also determine if we are using our resources appropriately and, in doing so, delivering evidence-based, highest-quality care. Technology simply for technology's sake may not always lead to the best outcomes. We must therefore critically evaluate the sensitivities and specificities of such advancements as well as balance the long- term effects and costs (financial and even adverse medical) that can come from their usage. Examples such as focused assessment sonography in trauma examinations and their use in the pediatric popula- tion, screening laboratories, and radiologic studies must all be critically evaluated. 16-20 The present state of knowledge and risks vs benefits of each will be addressed. Lastly, patient- and family-centered care needs to be at the forefront of what distinguishes the management of pediatric trauma. 21 Having the proper equipment and personnel for the basic trauma needs of children of all ages remains essential. However, recognition of the need to treat both patients and their families can help bring a more holistic approach to meeting the needs of our most vulnerable patients and their families. Consid- eration of the entire child and his or her family, and not just the injury (eg, the fracture in room one ), remains a crucial part of the challenge set forth in pediatric trauma care. Health care providers tend to underrecognize, undertreat, and fail to prevent pain and anxiety in children, and limit the impact of these stressors related to trauma. 21 This issue will there- fore also address pain management of the pediatric trauma patient, posttraumatic stress disorder rec- ognition, and prevention strategies. Although we still have a long way to go to optimize the care of injured children, this series should act as a roadmap for the broad range of care providers treating pediatric

trauma patients.

range of care providers treating pediatric trauma patients. REFERENCES 1. National Center for Injury Prevention and

REFERENCES

1. National Center for Injury Prevention and Control. WISQARS Injury Mortality Reports, 1999 - 2006. Available at: http:// webapp.cdc.gov/sasweb/ncipc/mortrate10_sy.html. Accessed

1/15/10.

2. Mullins RJ. A historical perspective of trauma system deve- lopment in the United States. J Trauma 1999;47(Suppl 3):

S8-S14.

3. Berger E. Lessons from Afghanistan and Iraq: the costly benefits from the battlefield for emergency medicine. Ann Emerg Med 2007;49:486-8.

4. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma center care on mortality. N Engl J Med 2006;354:366-78.

PEDIATRIC TRAUMA: A ROADMAP FOR COORDINATION AND CARE / SIMON VOL. 11, NO. 1 3

5.

The Preventive Health Amendments of 1984, Pub. L. 98-555 § 7, 98 Stat. 2854, 2856 (1984) (codified as amended at 42 U.

Institute of Medicine Committee on Pediatric Emergency

Hall JR, Reyes HM, Meller JT, et al. Outcome for blunt trauma is

Potoka DA, Schall LC, Ford HR. Improved functional

14. Taheri PA, Butz DA, Lottenberg L, et al. The cost of trauma center readiness. Am J Surg 2004;187:7-13.

6.

S.C. § 300w-9).

15. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med 2009;

Medical Services. In: Durch JS, Lohr KN, editors. Emergency

163:512-8.

7.

medical services for children. Washington, DC: National Academy Press; 1993.

16. Holmes JF, Gladman A, Chang CH. Performance of abdom- inal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007;42:1588-94.

8.

best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7.

17. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal

528-33.

outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824-34.

injuries after blunt torso trauma. Ann Emerg Med 2009;54:

9.

Bensard DD, McIntyre RC, Moore EE, et al. A critical analysis of acutely injured children managed in an adult level I trauma center. J Pediatr Surg 1994;29:11-8.

18. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changed tomography in emergency departments in the United States over time. Ann Emerg Med 2007;49:

10.

Farrell LS, Hannan EL, Cooper A. Severity of injury and

320-4.

mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units vs. other hospitals. Pediatr

19. Brenner DJ, Hall EJ. Computed tomography - an increasing source of radiation exposure. New Engl J Med 2007;357:

Crit Care Med 2004;5:5-9.

2277-84.

11.

Centers for Disease Control and Prevention. Guidelines for field triage of injured patients: recommendations of the national expert panel on field triage. MMWR 2009;58:RR-1.

20. Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks? Pediatr Radiol 2008;

12.

O Connor RE. Specialty coverage at non-tertiary care

Millin MG, Hedges JR, Bass RR. The effect of ambulance

38:635-44.

13.

centers. Prehosp Emerg Care 2006;10:343-6.

21. Ziegler M, Grenwald MH, DeGuzman MA, et al. Posttraumatic stress responses in children: awareness and practice among a

2005;115:1261-7.

diversions on the development of trauma systems. Prehosp Emerg Care 2006;10:351-4.

sample of pediatric emergency care providers. Pediatrics

Abstract:

The concept of a golden hour is a fixture in trauma care. There is a dearth of scientific proof for this concept but an abundance of con- troversy around how this concept should be interpreted, especially for pediatric trauma patients. Health care providers should instead focus on the golden opportunity, differ- ent for each patient, to provide the best care in the most appropriate environment for all injured children.

Keywords:

pediatric trauma; golden hour; pediatric emergency; trauma systems; interfacility transport

Pediatrics and Emergency Medicine, Divi- sion of Pediatric Emergency Medicine, Emory University School of Medicine, Chil- dren’s Healthcare of Atlanta, Atlanta, GA. Reprint requests and correspondence:

Wendalyn Little, MD, MPH, Pediatric Emer- gency Medicine, 1645 Tullie Circle, Atlanta, GA 30329. wendalyn.little@choa.org

1522-8401/$ - see front matter © 2010 Elsevier Inc. All rights reserved.

Golden Hour or Golden Opportunity:

Early Management of Pediatric Trauma

Wendalyn K. Little, MD, MPH

There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later but some- thing has happened in your body that is irreparable. R Adams Cowley MD 1

days or two weeks later — but some- thing has happened in your body that is

GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE VOL. 11, NO. 1 5

THE GOLDEN HOUR

The term golden hour is a fixture in the lexicon of trauma care. The phrase refers to a critical period in the care of trauma patients during which appropriate care may limit morbidity and increase survival. The origin of this term is difficult to trace. It may have evolved from an early description of the relationship between survival and time from injury to treatment on the battlefields of World War I. This analysis of French military data showed a decrease in mortality from battle wounds from 10% within 1 hour of treatment to 75% at 8 hours post- injury. 2 More recent medical literature often attributes the phrase golden hour to trauma surgeon R. Adams Cowley, MD, one of the early champions of organized trauma care. Dr Cowley conducted trauma research and wrote and spoke extensively on the subject of trauma care, and the coining of the term golden hour is often attributed to his speeches, yet none of his publications mentions or tests the theory of a golden hour in trauma care. 2,3 Modern support for the golden hour concept began in the 1960s when trauma care in the United States was in its infancy and civilian trauma systems were nonexistent. Military data from each of the world wars, the Korean Conflict and the war in Vietnam, show decreased combat mortality with the development of faster, more organized systems for the transport of injured troops from the battlefield to medical care facilities. 3,4 This in- creased survival was attributed in part to faster evacuation of wounded soldiers from the battlefield to the hospital by way of helicopter transport. 4 The 1960s and 1970s saw an increased interest in civilian trauma care. Federal legislation led the way for funding emergency medical services (EMS) standards and training. The American College of Surgeons published the first of many guidelines for trauma care in 1976. 4 Pioneers such as Dr Cowley championed trauma care as a specialty with its roots in general surgery. 5 Helicopter transport began to be seen as a means of quickly moving injured patients to hospitals; some hospitals began to devote specialized resources and teams to care for trauma victims, and the concept of regionalized trauma systems gained support from health care providers and governing bodies. 4,6

TRAUMA SYSTEMS AND TRANSPORT TO TRAUMA CENTERS

Early studies of trauma patients appeared to show increased survival with the development of these early trauma systems and continue to show

improved outcomes for severely injured patients cared for in dedicated trauma centers. 7,8 A core principal in many of these systems is the belief that critically injured patients are best cared for in designated trauma centers, even if transport from the field to these centers bypasses closer medical facilities. The combination of the concepts of the golden hour and the importance of trauma centers has been the impetus for the development of EMS policies such as rapid scene triage, minimization of on-scene treatment interventions in favor of rapid transport to emergency departments, and air eva- cuation of severely injured patients directly from the site of injury to designated trauma centers. These practices are not without cost, in money for equipment and staffing of helicopter transport and EMS resources. They are also not without risk to EMS teams, patients, and bystanders when priority is placed on rapid transport, sometimes across great distances. 9 A common debate in trauma system development centers on whether patients should be transferred longer distances to trauma centers or to the closest available facility, where initial stabilization may be performed, and then those patients determined to need further specialty care are then transferred to a trauma center. Much of the current literature supports a varied approach based on geographic location. In urban areas, where level I trauma centers are often readily available, it may make sense to bypass closer facilities to reach the trauma facility, as differences in transport times are likely to be minor. In rural areas, however, transport times to trauma centers may be pro- longed, and patients may benefit from stabiliza- tion in a closer facility followed by transfer to a trauma center after initial stabilization. Effective trauma systems must therefore take into account the location and capabilities of the facilities within a geographic catchment area, as well as any traffic or geographical features that may impact transport times. This approach to es tablishing effective trauma systems is perhaps best characterized by the 3R rule attributed to pioneering trauma surgeon Dr Donald Trunkey of getting the right patient to the right place at the right time. 10 Some patients may have only minutes to survive without appropriate intervention, whereas some may sur- vive their initial injuries but need specialized care and rehabilitation to achieve maximum post- injury function. This concept might well be the best guiding principle of trauma management, and the immediate postinjury period might best be thought of as a golden opportunity to ensure prompt, appropriate treatment for each and every injured patient.

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VOL. 11, NO. 1 GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE

PEDIATRIC TRAUMA AND TRAUMA CENTERS

If the concept of a golden hour and its relationship to trauma systems is controversial and unproven in adults, it is even more so for pediatric trauma patients. The development of pediatric emergency medicine as a specialty has promoted the creation of pediatric trauma centers, some as part of free- standing children's hospitals and others within general/adult facilities. Pediatric trauma care con- tinues to evolve as a distinct facet of trauma care that recognizes the different anatomical, physiolog- ic, and developmental realities of pediatric patients as well as the different injury patterns seen in these patients. The development and concentration of pediatric expertise has improved the management of injured children, with patients cared for in pediatric trauma centers appearing to have equal or better outcomes overall when compared to pediatric patients cared for in general or adult trauma centers. 11-17 Many factors likely contribute to this positive effect including the availability of appropriately sized equipment and monitoring capabilities for pediatric patients, health care providers capable of recognizing and treating the early, often subtle, signs of shock in pediatric patients, and management strategies unique to pediatric injuries. Despite evidence to suggest better outcomes for pediatric trauma victims treated in pediatric trauma centers, most pediatric trauma victims are cared for, at least initially, in nonpediatric centers, as the number and geographic location of dedicated pediatric centers leaves many children out of reach for immediate care. 12,13 The question that therefore arises is not only does a golden hour exist for the treatment of pediatric trauma patients, but also, what should occur during that initial time frame. One aspect of this debate centers on whether pediatric trauma patients should be transported directly to pediatric centers, possibly bypassing other emergency facilities or trauma centers on the way to specialized pediatric care, or should they be stabilized at the closest capable facility and then transferred to specialized pediatric centers if their condition warrants. It is worrisome that pediatric patients may be subjected to longer transport times, possibly bypassing adult trauma facilities to reach pediatric centers, as EMS providers often do not have great familiarity or experience with critically ill or injured children. The EMS pediatric volumes are often quoted as around 10% of EMS calls, with less than 1% of these patients meeting the definition of critically ill. The EMS personnel may have difficulty

performing procedures such as intravenous access, endotracheal intubation, and appropriate cardio- pulmonary resuscitation on pediatric patients. 14,15 There is literature to suggest similar outcomes for pediatric patients ventilated by means of bagging instead of endotracheal intubation in cases of respiratory failure, su ggesting that intubation should not be attempted in the field for pediatric patients in urban locations where transport times to hospital emergency departments is fairly short. 15 Another study examining the effectiveness of pediatric helicopter transport showed no benefit for patients transported directly from the scene of injury to a pediatric trauma center as compared with those initially stabilized at the closest medical facility. 17 All of this information could be inter- preted that time spent in EMS transport of critically ill and injured children should be minimized, and these patients should be transported to the closest facility able to provide stabilizing, if not definitive, care.

EMERGENCY DEPARTMENT READINESS FOR CHILDREN

If pediatric patients are to be transported to non pediatric-specific hospitals, the emergency depart- ments at these facilities must be capable of assessing pediatric trauma patients and providing stabilizing care (also see article Pediatric Patients in the Adult Trauma Bay Comfort Level and Challenges, in this issue). Although most emergency department visits in the United States involving children occur in nonpediatric facilities, many of these facilities are underprepared to deal with critically ill or injured children. In 2001, the American Academy of Pediatrics and the American College of Emergency Physicians established a set of guidelines for pediatric emergency department preparedness. 18 These guidelines, which were recently updated in 2009, address equipment, training, and quality review for pediatric care in emergency depart- ments. 19,21 Surveys evaluating preparedness con- tinue to show inadequate preparation in equipment and training for pediatric patients. 13,20,22 Nonpedia- tric centers often transfer seriously ill or injured patients to pediatric centers for definitive care. The presence of a seriously injured child may engender a sense of anxiety in the emergency department and has the potential to create a stress-laden atmo- sphere in which recognition and treatment of life- threatening shock and respiratory failure go unad- dressed and untreated in attempts to get the patient out of the facility and enroute to a pediatric

GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE VOL. 11, NO. 1 7

specialty center as quickly as possible. Missed injuries on an initial trauma survey are a common problem, and there is some evidence from adult studies that seriously injured patients transferred from rural hospitals to trauma centers frequently have unrecognized injuries. 23,24 This suggests that patients may have injuries overlooked in favor of rapid transport to a trauma center. This problem may be even more widespread for pediatric patients in similar situations. Recent literature supports early recognition and treatment of shock and respiratory failure as important in improving ulti- mate survival and outcome of critically ill or injured patients, both adult and pediatric. 25,26 Similarly, neurologic outcome has been shown to improve with early appropriate resuscitation and monitoring of children with traumatic brain injury. 27 Unfortu- nately, studies of pediatric patients transferred to pediatric centers describe deficiencies in the detec- tion and treatment of shock, hypotension, and respiratory failure before transfer. 18,25,26

INITIAL STABILIZATION OF INJURED CHILDREN

So what should be the scope of the evaluation and stabilization of pediatric trauma patients in general trauma facilities or community hospitals? A prima- ry survey focusing on airway, breathing, and circulation should be undertaken and any life- threatening conditions c orrected. All patients should be placed on supplemental oxygen. Ad- vanced airway management in the form of endotra- cheal intubation may be needed in patients with severe traumatic brain injury, thoracic injuries, or shock. Adequate oxygenation and ventilation should be ensured. A portable chest radiograph to evaluate for pneumothorax may be helpful. Placement of a thoracostomy tube should be pursued for most cases of pneumothorax. Close attention should be paid to the child's hemodynamic status. Health care provi- ders must keep in mind that the strong compensa- tory mechanisms in children and teenagers allow them to increase their systemic vascular resistance and maintain blood pressure until a substantial amount of blood is lost. 19,28 Early signs of shock such as tachycardia, mental status, and capillary refill time are more sensitive and should be monitored closely. An initial fluid bolus of isotonic saline should be administered and repeated as needed. Blood component transfusion should be considered for patients not responding to crystalloid resuscitation or for those with evidence of ongoing hemorrhage. 27 Patients with immediately life-

threatening hemorrhage would seem to be candi- dates for immediate transfer to a trauma center with pediatric surgeons and a pediatric intensive care unit but at times may require the services of a general surgeon, if available, to control hemorrhage before transport. Most pediatric trauma is caused by blunt mechanism of injury such as falls, motor vehicle collisions, assault, and sporting activities. Most patients will not require emergent surgical intervention. Pediatric trauma specialists have led the development of protocols for expectant, nonop- erative management of some conditions, namely liver and splenic injuries. In adult-oriented systems, these injuries are generally treated surgically, whereas children cared for in pediatric centers are usually managed nonoperatively. Therefore, pediat- ric patients undergo fewer laparotomies and sple- nectomies than do adult patients. 29,30 The golden hour for these patients might best be spent ensuring adequate oxygenation and ventilation, securing an airway if needed, obtaining vascular access, and providing initial fluid r esuscitation if needed. Patients with traumatic brain injury must be carefully monitored, and hypotension and hypoxia avoided as both of these states have been found to be independent predictors of increased mortality in patients with traumatic b rain injury. Pediatric patients with isolated brain injuries may best be stabilized at the closest medical facility in which these conditions may be recognized and corrected as needed. Transport could then be undertaken in a controlled fashion and preferably with a specialized pediatric critical care transport team. Time should not be spent obtaining computerized tomography and other extensive imaging studies if the facility lacks the surgical capabilities to provide definitive care for injuries detected on imaging or if obtaining scans will delay transport. Scans may inadvertently fail to be transported with the patient or, in the case of digital images, transferred by compact disk, inaccessible at the receiving facility, thus, necessi- tating repeat imaging with increased costs and unnecessary radiation exposure to the patient. In fact, one study found that almost all radiographs performed at referring facilities were later repeated when patients arrived to the trauma center. 31 Once critically ill or injured children are stabi- lized and the decision is made to transfer to a pediatric trauma center, attention must then be turned to the best mode of transfer. One recent study showed significantly more complications and deaths (23% mortality vs 9% mortality) among pediatric patients transferred from referring facili- ties to a pediatric trauma center by general helicopter teams vs specialized pediatric teams.

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VOL. 11, NO. 1 GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE

This

remained true even when corrected for patient

mix

and the greater average time from referral to

arrival in the pediatric center among patients transported by the specialty teams. The authors speculate that despite overall longer transport times, the patients transported by the specialized team actually benefited from an overall longer period in the care of pediatric specialists. 18 This concept of bringing the hospital to the patientmay in fact be a critical piece of care that is currently lacking in many trauma systems. Several studies have shown that transport by specialty-trained mobile intensive care unit teams is associated with improved outcomes, even if such transport delays ultimate patient arrival at the tertiary care

center. 18,19 , 28-44

THE GOLDEN OPPORTUNITY

So what is the best care for pediatric trauma patients? How can a system capitalize on the

golden opportunity to provide the right care in

the right place at the right time? Creation of

regionalized trauma systems to ensure timely access to basic evaluation and stabilization for all patients

is vital. 45 This may require initial transport of pediatric trauma patients to general emergency facilities, especially in rural areas without immedi- ately available pediatric trauma centers. These

facilities must be capable of evaluating and stabiliz- ing pediatric trauma patients. Appropriately sized equipment and monitoring capabilities must be present. Staff must have skills in the assessment

and stabilization of pediatric patients, especially in

the management of shock and real or impending respiratory failure. Pediatric patients with severe or life-threatening inju ries, especially those in need of intensive care unit-level care, should then

be transferred to appropriate pediatric trauma faci- lities as rapidly as possible after initial stabilization of any immediately life-threatening conditions. The criteria for transfer and mechanisms for referral

and transfer must be put in place and maintained.

Transfer agreements between general and pediatric trauma centers must be well designed with prompt, easily accessed communication readily available between facilities to expedite transfers. Careful consideration should be given to the mode of transfer and composition of the transport team. For many pediatric patients, this may mean await- ing the arrival of specialized transport teams from the receiving institution. In these situations, per- sonnel at the referring facility must be capable and remain committed to caring for the patient until the team arrives. They must adopt a mentality of

ongoing treatment vs awaiting transfer and be capable of recognizing and responding to evolving clinical changes in pediatric patients.

SUMMARY

Certainly, no one would argue that timely care is best for critically ill and injured persons. However, the exact meaning and significance of a golden hour in trauma care is the subject of debate and controversy. So is there a golden hour? If there is, then what should occur during this time? Should this time be spent transferring a patient from the scene to a major trauma center, even if it is not the closest facility? Or should patients be stabilized at the closest medical facility before transfer? Fur- thermore, how do the concepts of a golden hour and trauma system care apply to pediatric patients? Perhaps, the answers lie somewhere in between, and rather than a golden hour, health care providers should focus on the golden opportunity to provide stabilization of immediately life-threat- ening conditions at the closest appropriate facility followed by safe transfer when needed for definitive care. True realization of this opportunity for pediatric trauma patients requires individualized consideration for each patient within well-estab- lished and well-coordinated systems of regionalized

trauma care.

and well-coordinated systems of regionalized trauma care. REFERENCES 1. www.umm.edu/shocktrauma/history.htm .

REFERENCES

1. www.umm.edu/shocktrauma/history.htm. Accessed Decem- ber 10, 2009.

2. Trauma.org. Trauma resuscitation. Available at: http://www. trauma.org/archive/history/resuscitation.html . Accessed August 11, 2009.

3. Lerner EB, Moscati RM. The golden hour: scientific fact of medical urban legend. Acad Emerg Med 2001;8:758-60.

4. Mackersie RC. History of trauma field triage development and the American College of Surgeons criteria. Prehosp Emerg Care 2006;10:287-94.

5. Cowley RA. Accidental death and disability: the neglected disease of modern societywhere is the fifth component. Ann Emerg Med 1982;11:582-5.

6. Sasser SM, Hunt RC, Sullivant EE, et al. Guidelines for field triage of injured patients. MMWR 2009;58:1-35.

7. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366-78.

8. Nathens AB, Jurkovich GJ, Rivara FP, et al. Effectiveness of state trauma systems in reducing injury-related mortality: a national evaluation. J Trauma 2000;48:25-31.

9. Larson JT, Dietrich AM, Abdessalam SF, et al. Effective use of the air ambulance for pediatric trauma. J Trauma 2004;56:

89-93.

10. Traumafoundation.org. Trauma's golden hour. Available at:

GOLDEN HOUR OR GOLDEN OPPORTUNITY / LITTLE VOL. 11, NO. 1 9

%20Care_Golden%20hour.pdf. Accessed 10/27/2009.

11. Potoka DA, Schall LC, Gardner MJ, et al. Impact of pediatric trauma centers on mortality in a statewide system. J Trauma

2000;4:237-45.

12. Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. J Trauma 2001;51:824-34.

13. Odetola FO, Miller WC, Davis MM, et al. The relationship

between the location of pediatric intensive care unit facilities and child death from trauma: a county-level ecologic study.

J Pediatr 2005;147:74-7.

14. Osler TM, Vane DW, Tepas JJ, et al. Do pediatric trauma

centers have better survival rates than adult trauma centers? An examination of the national pediatric trauma registry.

J Trauma 2001;50:96-101.

15. Farrell LS, Hannan EL, Cooper A. Severity of injury and

mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units versus other hospitals. Pediatr Crit Care Med 2004;5:5-9.

16. Nakayam DK, Copes WS, Sacco W. Differences in trauma care among pediatric and nonpediatric trauma centers.

J Pediatr Surg 1992;27:427-31.

17. Hall JR, Reyes HM, Meller JL, et al. The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 1996;31:72-7.

18. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, American College of Emergency Physicians, Pediatric Committee. Care of children in the emergency department: guidelines for preparedness. Pediat- rics 2001;107:777-81.

19. Gausche-Hill M, Krug SE, American Academy of Pediatrics Committee on Pediatric Emergency Medicine American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association, Pediatric Committee. Guide- lines for the children in the emergency department. Pediatrics 2009;124:1233-43.

20. Nance ML, Carr BG, Branas CC. Access to pediatric trauma care in the United States. Arch Pediatr Adolesc Med 2009;163:512-8.

21. Athey J, Dean M, Ball J, et al. Ability of hospitals to care for pediatric emergency patients. Pediatr Emerg Care 2001;17:

170-4.

22. Gausche M. Differences in the out-of-hospital care of children and adults: more questions than answers. Ann Emerg Med

1997;29:776-9.

23. Kumar VR, Bachman DT, Kiskaddon RT. Children and adults in cardiopulmonary arrest: are advanced life support guide- lines followed in the prehospital setting. Ann Emerg Med

1997;29:743-7.

24. Seidel JS, Hornbein M, Yoshiyama K, et al. Emergency medical services and the pediatric patient: are the needs being met. Pediatrics 1984;73:769-72.

25. Seidel JS. Emergency medical services and the pediatric patient: are the needs being met? II. Training and equipping emergency medical services providers for pediatric emer- gencies. Pediatrics 1986;78:808-12.

26. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of- hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;

283:783-90.

27. Larson JT, Dietrich AM, Abdessalam SF, Werman HA. Effective use of the air ambulance for pediatric trauma. J Trauma 2004;56:89-93.

28. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics

2007;120:1229-37.

29. Aaland MO, Smith K. Delayed diagnosis in a rural trauma center. Surgery 1996;120:774-9.

30. Robertson R, Mattox R, Collins T, et al. Missed injuries in a rural area trauma center. Am J Surg 1998;12:564-8.

31. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics 2003;112:

793-9.

32. Carcillo JA, Kuch BA, Han YY, et al. Mortality and functional morbidity after use of PALS/APLS by community physicians. Pediatrics 2009;124:500-8.

33. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation of children with moderate-to-severe traumatic brain injury. Pediatrics 2009;124:56-64.

34. Orr RA, Felmet KA, Han Y, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics 2009;124:40-8.

35. American Heart Association. PALS provider manual. Dallas (Tex): American Heart Association; 2002.

36. American College of Surgeons. Advanced Trauma Life Support for Doctors. 7th ed. Chicago (Ill): American College of Surgeons; 2004.

37. Davis DH, Localio AR, Stafford PW, et al. Trends in operative management of pediatric splenic injury in a regional trauma system. Pediatrics 2005;115:89-94.

38. Mooney DP, Rothstein DH, Forbes PW. Variation in the management of pediatric splenic injuries in the United States. J Trauma 2006;61:330-3.

39. Keller MS, Vane DW. Management of pediatric blunt splenic injury: comparison of pediatric and adult trauma surgeons.

J Pediatr Surg 1995;30:221-5.

40. Hall JR, Reyes HM, Meller JL, et al. The outcome for children

with blunt trauma is best at a pediatric trauma center.

J Pediatr Surg 1996;31:72-7.

41. Thomas SH, Orf J, Peterson C, et al. Frequency and costs of laboratory and radiograph repetition in trauma patients undergoing interfacility transfer. Am J Emerg Med 2000;18:

156-8.

42. Bellingan G, Oliver T, Batson S, Webb A. Comparison of a specialist retrieval team with current United Kingdom practice for the transport of critically ill patients. Intensive Care Med 2000;26:740-4.

43. Valenzuela TD, Criss EA, Copass MK, et al. Critical care air transportation of the severely injured: does long distance transport adversely affect survival. Ann Emerg Med 1990;19:

169-72.

44. McPherson ML, Graf JM. Speed isn't everything in pediatric medical transport. Pediatrics 2009;124:381-3.

45. Tuggle D, Krug SE, American Academy of Pediatrics, Section on Orthopedics, Committee on Pediatric Emergency Medi- cine, Section on Critical Care, Section on Surgery, Section on Transport Medicine, Pediatric Orthopedic Society of North America. Management of pediatric trauma. Pediatrics 2008;

121:849-54.

Abstract:

A limited body of literature about pediatric prehospital trauma care exists to date. Topics that have been studied include delaying transport to initiate treatment on-scene, the use of advanced life support or basic life support resources, identifying high-risk pediatric trauma patients, optimal airway management, obtaining intravenous or intraosseous access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Translating the best available evidence into clinical practice is important to providing quality prehospital pediatric trauma care. This article will review the literature regarding the risks and benefits of various aspects of pediatric trauma care in the prehospital setting.

Keywords:

pediatric trauma; intravenous access; intraosseous access; cervical spine immobilization; traumatic brain injury; prehospital care; airway; emergency medical services

Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, Houston, TX. Reprint requests and correspondence:

Manish I. Shah, MD, Texas Children’s Hospital, 6621 Fannin Street, MC 1-1481, Houston, TX 77030. mxshah@texaschildrens.org

1522-8401/$ - see front matter © 2010 Elsevier Inc. All rights reserved.

Prehospital Management of Pediatric Trauma

Manish I. Shah, MD

R ecent estimates from the National Hospital Ambulatory

Medical Care Survey database note that 27% of all

emergency department (ED) visits in the United States

are by children younger than 19 years, and 13% of all

patients transported via Emergency Medical Services (EMS) are children. Although the percentage of children who require EMS is small relative to adults, the acuity of pediatric EMS patients is often higher than that of adults. This is especially true with trauma, in which 54% of pediatric trauma patients arrive to the ED via EMS. 1 As the EMS system in the United States was originally designed to meet the needs of adults, the integration of the unique needs of children into the existing EMS infrastructure has been one of the main goals of the federally funded Emergency Medical Services for Children program for the past 25 years. 2 Twenty years ago, Ramenofsky 3 described essential compo- nents of an integrated pediatric trauma system that addressed system design, prevention, education, standards of care, research and development, quality assurance, and funding. Successfully integrating the needs of children into the existing EMS infrastruc- ture involves initiating high-quality prehospital care that uses preestablished protocols. These protocols must then be applied by skilled emergency medical technicians (EMTs) with the assis- tance of online medical control until ultimate transport to an appropriate facility capable of providing definitive care. Although much has been accomplished in each of these areas for pediatric trauma, there are still many areas that have not been adequately addressed. One of these is the incorporation of evidence-based practices into prehospital care. This concept was highlighted in the recent Institute of Medicine (IOM) report, The Future of Emergency Care, which describes the importance of extending evidence-based practices into prehospital care. 4 Although the prehospital pediatric literature is limited to date, evaluating the literature for risks and benefits of various aspects of pediatric trauma care in the prehospital setting is an important

PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH VOL. 11, NO. 1 11

way to determine the value of certain decisions in the field. These include delaying transport to initiate treatment on-scene, the use of advanced life support (ALS) or basic life support (BLS) resources, identi- fying high-risk pediatric trauma patients, optimally managing the airway, obtaining intravenous (IV) or intraosseous (IO) access, immobilization of the cervical spine, optimal management of traumatic brain injury, and the assessment and management of pain. Each of these areas has been controversial in the management of pediatric trauma patients, and examination of the literature is important in determining local protocols.

PREHOSPITAL CARE TIME

Some literature suggests that prehospital care time has a significant impact on survival in severely injured patients and is a major component of the golden hour of trauma care. 5 Yet the impact of response time intervals on morbidity and mortality of all trauma patients is unclear. 6 In a meta-analysis designed to describe average time intervals of prehospital care, 4 time intervals were defined and analyzed: (1) an activation time interval (ATI) in the prealarm period defined as the time from receiving the call to the time of alarm, (2) a response time interval (RTI) defined as the time from alarm to arrival on-scene, (3) an on-scene time interval (OSTI) defined as the time from on-scene arrival to departure, and (4) a transport time interval (TTI) defined as the time from scene departure to arrival at a hospital. Average urban and suburban ground ambulance time intervals were similar to each other (ATI = 1 minute; RTI = 5 minutes; OSTI = 14 minutes; and TTI = 11 minutes) and significantly shorter than those for rural ground ambulances (ATI = 3 minutes; RTI = 8 minutes; OSTI = 15 minutes; and TTI = 17 minutes). The average overall prehospital care time for urban/suburban settings was 31 minutes compared to 43 minutes in the rural setting. Helicopter transport times were significant- ly longer than those for ground ambulances as a whole but were not compared by setting. 7 Using these national averages as a benchmark may be useful in evaluating the quality of pediatric prehospital trauma care. Although standards exist for time to definitive care for acute coronary syndrome and stroke patients the impact of similar prehospital care time standards for trauma patients is still unclear. The American College of Surgeons does strongly encourage rapid transport to a trauma center and minimization of on-scene time for trauma patients, and there is evidence to support improved outcomes with shorter on-scene times. 5,8

PREHOSPITAL TRIAGE AND TRANSPORT

Regionalizing trauma care has demonstrated improved outcomes in pediatric trauma and has been recommended by the IOM. 4,9 Determining which patients are at high risk for mortality or need specialized treatment that can only be provided at a trauma center with pediatric capabilities is impor- tant. Using prehospital triage criteria that balances

sensitivity and specificity to transport patients with

the most severe injuries to trauma centers, while

transporting those with less severe injuries to the closest hospital, is essential in regionalizing trauma

care for children.

Engum et al 10 performed a retrospective analysis of the predictive value of certain physiologic and anatomical criteria in determining pediatric trauma patients who subsequently died in the ED, were admitted to the pediatric intensive care unit, or required a major surgical procedure. Their findings showed that 5 criteria had a positive predictive value of 50% or higher, a systolic blood pressure (SBP) of less than 90 mm Hg (86%), Glasgow Coma Score (GCS) of 12 or less (78%), respiratory rate (RR) of less than 10/min or more than 29/min (73%), a second- or third-degree burn involving more than 15% total body surface area (79%), or paralysis (50%). Yet this analysis did not take into account varying normal vital sign values by age group, thus drawing some criticism on the utilization of SBP less than 90

mm Hg and RR of more than 29/min as predictors of

poor outcomes in young children. Newgard et al 11 analyzed a retrospective cohort of injured children in the Oregon state trauma registry over a 6-year period and included age-based physiologic para- meters to identify children at high risk for major nonorthopedic operative intervention, intensive care unit stay of 2 days or longer, or in-hospital mortality. They found that the GCS was the most important prehospital predictor followed by (in order) airway intervention, RR, heart rate (HR), SBP, and shock index. Examining the findings of Newgard et al 11 in reference to those of Engum et al, 10 a RR of more than 29/min had no predictive

value in children younger than 5 years of age and HR

was significantly more predictive of poor outcomes

in comparison to SBP or shock index. Yet, Newgard et al 12 performed a subsequent analysis on pediatric patients using the American College of Surgeons Committee on Trauma field decision criteria to develop a clinical decision rule to identify high-risk injured children. The decision rule placed these criteria in the following order to identify high-risk injured children: need for assistance with

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VOL. 11, NO. 1 PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH

ventilation via endotracheal intubation (ETI) or bag- valve-mask ventilation (BVM), GCS of less than 11, pulse oximetry of less than 95%, and SBP of more than 96 mm Hg. Of note, HR and RR did not prove to be important predictors in the model. In addition, the finding of a high SBP associated with poor outcomes may be plausible with traumatic brain injury but otherwise did not seem to be expected. Therefore, pediatric patients with prehospital find- ings of a low GCS, the need for airway interventions, hypoxia, and hypertension seem to be at high risk for poor outcomes. These predictors should potentially be incorporated into decision-making protocols for transport of pediatric patients to a trauma center. 12 The use of ALS vs BLS for the transport of trauma patients in the prehospital setting has stirred debate, given the resource implications of using ALS for each patient, the lack of adequate ALS staffing in rural areas, and the assumption that prehospital ALS decreases morbidity and mortality. 13,14 Staffing an ALS unit compared to a BLS unit is estimated to cost an extra $94 928 per year per unit. 15 Also, procedures performed by ALS units take additional time, which may delay ultimate transport to definitive care. 16 A meta-analysis evaluating 15 studies, including patients of all ages, concluded that ALS-treated trauma patients overall had an increased odds of mortality over BLS-treated patients (odds ratio [OR], 2.92). Interpretation of the confidence intervals (CIs), however, revealed only one study that favored ALS. The other studies had CIs that included 1, therefore did not show a significant difference. 17 One study from Finland reported slightly improved outcomes in ALS units staffed by a physician, but this model is rare in the United States. 18 Thus, it seems that there is no difference in mortality between ALS and BLS trauma care when provided by EMTs, but there are significant differences in cost with possible benefit only in situations of prolonged transport times or physician-staffed ALS units.

AIRWAY MANAGEMENT

One of the most controversial topics in prehospi- tal care is the method of airway management that reduces morbidity and mortality while optimizing safety. This is also an issue in adult trauma care, and a retrospective cohort analysis of trauma patients older than 14 years demonstrated that prehospital care time for patients undergoing rapid sequence intubation (RSI) was 10.7 minutes longer (95% CI, 7.7-13.8) than patients who were not intubated. Also, prehospital care time for patients undergoing conventional ETI without induction medications

was still 5.2 minutes longer than that for patients who were not intubated. 19 Thus, intubation clearly increases on-scene time, which may result in poorer outcomes for patients. In a separate analysis of the same cohort, adjusting for the propensity to be intubated, prehospital ETI was associated with an increased odds of mortality (OR, 2.70; 95% CI, 1.63-4.46) when ground transport distances were short ( b 10 miles) compared to nonintubated patients. This risk gradually declined as ground transport dis- tance increased, such that the 95% CI included an OR of 1 for transport distances greater than 20 miles. Intubated patients transported by helicop- ter, however, had decreased mortality (OR, 0.36; 95% CI, 0.24-0.56). This finding may be due to the more advanced airway management skills of air transport providers, but the evidence suggests that ETI in adults by ground crews near a hospital increases mortality. 20 In a controlled trial of pediatric patients in the urban setting who either received BVM or ETI for prehospital airway management, intention-to-treat analysis revealed that there was no difference between the 2 interventions for both survival and neurologic outcome, even in the subgroup analysis of various categories of trauma patients including submersion injury, head injury, and multiple trau- ma. The subgroup of child maltreatment patients demonstrated improved survival with BVM com- pared to ETI (OR, 0.07; 95% CI, 0.01-0.58), but there was no significant difference in neurologic outcome. This study, however, did not examine potential effect measure modification by transport distance. 21 Maintenance of the rarely encountered task of prehospital pediatric ETI, the anatomical differ- ences of the pediatric airway relative to an adult, and the limited pediatric continuing education for prehospital providers make pediatric ETI a chal- lenging task for the prehospital provider, especially in the rural setting. In rural pediatric trauma patients, field intubation success rates by both EMT-paramedics and flight registered nurses are significantly poorer (45%-70%) when compared to rates by ED physicians and anesthesiologists at trauma centers (89%-100%). 22 Therefore, the risk of increased on-scene time and potential complications with ETI must be weighed against the benefit of rapid transport to an appropriate trauma center when deciding whether to intubate or use less invasive means to manage the airway of a pediatric trauma patient. This may be especially true for ground transport distances less than 10 miles, in which higher mortality has been demonstrated in the adult population.

PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH VOL. 11, NO. 1 13

INTRAVENOUS AND IO ACCESS AND INFUSIONS

Because many time intervals in prehospital care are system dependent, the most effective way to decrease prehospital times is to decrease the on- scene duration. Procedures in the field may increase

the likelihood of survival or may increase mortality

by

delaying definitive care. In a retrospective review

of

IV placement in trauma patients of all ages, this

procedure added an additional 5 minutes of on- scene time. 16 Because this study did not include a subgroup

analysis of pediatric patients, however, the time to place an IV in a child may actually be longer. A retrospective chart review of prehospital IV place- ment in pediatric patients, with subgroup analysis for trauma patients, showed a 57% success rate for

IV placement in patients less than 6 years of age and

74% success rate in age 6 years or higher. Average time to IV placement in trauma patients was 14 minutes (range, 7-24 minutes) in age less than 6 years and 12 minutes (range, 1-43 minutes) in age more than 6 years. 23 For some patients, decreasing on-scene time may be essential to survival, but for others, the benefit of initiating IV access may outweigh the risks. Therefore, the determination of whether to place an IV needs to be based on the individual patient with respect to expected trans- port time and anticipated time to complete the procedure. Although obtaining IV access in pediatric patients may prolong on-scene time by up to 14 minutes, placement of an IO needle may provide more timely access for trauma patients with hemorrhagic shock. In a prospective observational study of paramedics after a brief training session on the placement of IO needles, 28 (84%) of 33 of the attempted IO infusions were successfully started in less than 1 minute in a simulated ambulance setting at a speed of 25 to 35 miles per hour. 24 In a

retrospective cohort of pediatric trauma patients in whom an IO was attempted for cardiopulmonary arrest, hypovolemic shock, or neurologic insult, successful placement by prehospital professionals was noted in 13 (93%) of 14 cases. These IO needles were used both in the prehospital and emergency department settings to successfully administer both colloid and crystalloid infusions and multiple pharmacologic agents in patients 3 months to 10 years of age, with only one reported case of minor tissue extravasation. 25 Regardless of whether an IV or IO is placed, controversy exists about whether administration of fluids in the prehospital setting actually improves

patient outcomes. Computer modeling to evaluate the potential benefit of administering prehospital fluids for major hemorrhage suggests that only trauma patients who had a bleeding rate of more than 25 mL/min and prehospital time greater than 30 minutes would benefit. 26 Yet these findings have not been validated in children in the prehospital setting. The only study evaluating the efficacy of prehospital IV fluid administration to pediatric trauma patients was a retrospective review in which it was inconsequential in 94% of patients, potentially beneficial in 4% of cases, and potentially harmful in 2% of cases. 27 It seems evident that adult trauma protocols may not be applicable to children, prehospital IV placement prolongs on-scene time, and the benefit of prehospital fluid therapy in pediatric trauma patients is still unclear. 28 Yet given the physiologic differences between children and adults, IV/IO fluid administration for hemorrhage secondary to trauma may be warranted. For some patients, decreasing on-scene time may be essential to survival, but for others, the benefit of initiating IV access may outweigh the risks. Therefore, the determination of whether to place an IV or IO needs to be based on the individual patient with respect to expected transport time and anticipated time to complete the procedure.

CERVICAL SPINE IMMOBILIZATION

Common practice among prehospital profes- sionals is to immobilize the cervical spine of a patient who has had a traumatic injury. Once these patients arrive at the hospital, the cervical immo- bilization device might be removed based on clinical criteria, or the patient might undergo further imaging. The National Emergency X-Radi- ography Utilization Study (NEXUS) derived and validated a decision rule to determine who can safely have a cervical spine immobilization device removed in the ED without radiographic evalua- tion. 29 Although these data apply to patients who have already been immobilized, it is plausible that some EMS agencies may attempt to apply these findings to the prehospital setting. To date, there are no published studies that provide evidence that prehospital professionals can forego cervical spine immobilization using the NEXUS criteria. Because only 10% of the patients in NEXUS were children, applying these findings to the prehospital care of children would be even more difficult. 29,30 Analysis of the NEXUS pediatric patient data demonstrates that no cervical spine injury would have been missed if the NEXUS criteria had been applied to

14

VOL. 11, NO. 1 PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH

this population. 30 Yet due to the low cervical spine injury rate of 0.98% in pediatric trauma patients in this study, it would be difficult to safely apply this rule to children in the ED setting, let alone the prehospital setting. 30 Until this issue is studied further, children with a significant mechanism of injury should have their cervical spine immobilized using age-appropriate equipment before transport to the hospital.

TRAUMATIC BRAIN INJURY

Traumatic brain injury (TBI) in children results from a variety of causes, including nonaccidental injury, falls, and motor vehicle collisions. 31 In the young athlete, TBI occurs with activities such as football, soccer, cheerleading, basketball, and field hockey. 32 Because athletic injuries and motor vehicle collisions are common causes of pediatric TBI, the prehospital professional must be equipped to manage these common mechanisms of injury. 33 In addition, because 50% of the mortality due to TBI occurs in the first 2 hours after injury, prehospital assessment and management of TBI is crucial. 34 Yet variation exists in assessing and managing children with TBI in the prehospital environment, and an evidence-based approach is necessary. 31 Early correction of hypoxemia and hypotension, accurate assessment of the GCS and pupils, airway management, and appropriate transport decision making is vital, according to the Brain Trauma Foundation's evidence-based guidelines on prehos- pital management of TBI. Most of these guidelines are based on adult studies, however, due to relatively limited studies on pediatric TBI in the prehospital setting. Regardless, modifying the GCS for a pediatric patient is essential due to differences in preverbal children ( Table 1 ). 35 In addition, the assessment of potential TBI should include asking the verbal child about a recent prior head injury and symptoms of a concussion, such as headache, dizziness, nausea, and blurred vision. In addition, it is also important to ask bystanders about loss of consciousness and the mechanism of injury. Physical assessment should include evaluation of the face and scalp for hematomas, ecchymoses, or palpable skull fracture; drainage of blood from the ears or nose; and a thorough neurologic examination, including an age- adjusted assessment of the GCS. 31 In a recent analysis of a prospective cohort of children with head injuries, patients 2 years or older with altered mental status, any suspected or confirmed loss of consciousness, history of vomit- ing, severe mechanism of injury (motor vehicle

collision with patient ejection, death of another passenger or rollover, pedestrian or bicyclist without helmet struck by a motorized vehicle, falls of N 5 feet, head struck by a high-impact object), clinical signs of basilar skull fracture (posterior auricular or periorbital ecchymoses, hemotympanum, or cerebrospinal fluid otorrhea/

rhinorrhea), or a severe headache were at risk for

a clinically significant TBI, which may require

neurosurgical intervention or hospital admission. Patients younger than 2 years with altered mental status, occipital/parietal/temporal scalp hematoma, loss of consciousness for 5 seconds or more, severe mechanism of injury, palpable or equivocal skull fracture, or abnormal behavior according to the caregiver were also at risk for clinically important TBI. 36 Being aware of what makes a pediatric patient high risk for complications from TBI is especially essential for EMS systems in which EMTs can determine patient disposition in the prehospital setting. This is also true in the case of potential nontransport of patients after sports injuries be- cause providers must be aware of the sequelae of TBI and recommendations to return to play after sports-related injuries. 31

For example, sports-related TBI can result in a clinical entity called second impact syndrome, in which

a second concussion in a patient who is still

symptomatic from a first concussion can result in cerebral edema, brain herniation, coma, and

death. 37 To prevent second impact syndrome, the Concussion in Sport Group has published recom- mendations on short-term management and when

to return to play. These recommendations state that

any player that shows symptoms of headache, dizziness, nausea, or double vision should refrain from the current sports activity, under medical evaluation, and should only return to play when asymptomatic with a normal neurologic and cogni-

tive evaluation. 38 Also, patients who experience a loss of consciousness should be transported to a hospital for further evaluation. 39 The prehospital management of TBI focuses on minimizing secondary injury, essentially through handling the compromised airway and intervening

to prevent hypotension. Hypoxemia (oxygen satu-

ration, b 90%) should be avoided by managing the airway by the most appropriate means, which may

be supplemental oxygen, BVM, ETI, or other airway

adjuncts. 35 There is no evidence to support ETI over BVM in pediatric patients with TBI, however, and pediatric trauma patients as a whole may have fewer complications from BVM when compared

to ETI. 21

PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH VOL. 11, NO. 1 15

TABLE 1. Comparison of pediatric GCS with standard GCS

GCS

Pediatric GCS

Eye opening

Eye opening Spontaneous Speech Pain None Verbal response Coos, babbles Irritable cries Cries to pain Moans to pain None Motor response Normal, spontaneous Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None

 

Spontaneous

4

4

Speech

3

3

Pain

2

2

None

1

1

Verbal response

Oriented

5

5

Confused

4

4

Inappropriate

3

3

Incomprehensible

2

2

None

1

1

Motor response

Obeys command

6

6

Localizes pain

5

5

Flexor withdrawal

4

4

Flexor posturing

3

3

Extensor posturing

2

2

None

1

1

Data from Badjatia. 35

Children with suspected TBI should have their cervical spine (C-spine) immobilized in the field due to risk for concurrent injury. 31 If ETI is going to be attempted, manual C- spine stabilization is necessary to prevent secondary injury. For EMS agencies that use RSI medications for intubation, premedication with 1.5 mg/kg of lidocaine followed by 0.3 mg/kg of etomidate for sedation and either 1.5 mg/kg of succinylcholine or 1 mg/kg of vecur- onium are preferred to protect against increases in intracranial pressure. Otherwise, the decision to intubate should be made in consultation with online medical control if these RSI medications are not available for use in the prehospital setting. Signs of increased intracranial pressure are represented by Cushing's triad of hypertension, bradycardia, and irregular breathing. 31 The EMS systems that use RSI protocols should monitor blood pressure, oxygenation, and end-tidal CO 2 (ETCO 2 ). Patients should be maintained with normal breathing rates (ETCO 2 = 35-40 mm Hg), and hyperventilation (ETCO 2 b 35 mm Hg) should be avoided unless there are signs of cerebral herniation. The evidence for the latter, however, is lacking in pediatrics, and this recommendation has been extrapolated from adult data. 35 Because hypotension with TBI in pediatric patients has been associated with poor outcomes,

blood pressure should be monitored with an appropriately sized pediatric cuff and prevented by giving boluses of 20 mL/kg of isotonic crystalloid (Table 2). 31,35 Prehospital providers should determine the GCS and pupil size after airway, breathing, and circula- tion have been assessed and stabilized. The most appropriate airway should be established in patients with severe TBI, defined as a GCS less than 9. 35 Also, because hypoglycemia can result after TBI, blood glucose should be checked and treated when serum glucose is less than 80 mg/dL. 31 Prehospital providers should directly transport children with severe TBI to a pediatric trauma center or an adult trauma center with added qualifications to treat children. 35 Because nonacci- dental head injury is also a common cause of death in infants, prehospital providers should thoroughly document findings at the scene and report unclear or implausible mechanisms to law enforcement, child protective services, and ED personnel, while being cautious to maintain scene safety. 31

PAIN ASSESSMENT AND MANAGEMENT

Pain assessment and management in trauma is important for patient comfort and potentially for patient healing. In a retrospective chart review of 696 pediatric trauma patients, prehospital person- nel documented a pain assessment in 81% of cases, but only 0.1% actually used a pain assessment tool. Of the 64% of patients with documented pain, only 15% received some sort of intervention to address their pain. For all patients, both pharmacologic and nonpharmacologic interventions were used equally in 13.4% of cases. 40 Because pain does not necessarily correlate with injury severity, pain assessment should occur in all children in the prehospital setting with a traumatic injury. In addition, parental report of pain is often

TABLE 2. Definition of pediatric hypotension by age

Age

SBP

0-28 days 1-12 months 1-10 years N 10 years

b60 mm Hg b70 mm Hg b70 + (2 × age in years) b90 mm Hg

Data from Badjatia. 35

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comparable to a child's report and should be incorporated into a pain assessment. 41 Although pediatric pain scales that have been validated in the hospital setting have not been validated in the prehospital setting, the use of standardized and age-appropriate pain assessment tools by prehospi- tal professionals is more likely to lead to manage- ment of pain. 42

SUMMARY

Prehospital providers play an essential role in the initial management of pediatric trauma patients by minimizing secondary injury and

transporting injured children to definitive care in

a timely manner. As the IOM has recently

recommended, it is essential for the United States

to have an EMS system that is regionalized and

coordinated to provide optimal care in a seamless

fashion along the continuum from the prehospital

to ED settings. 4 Although the evidence base for

pediatric prehospital trauma care is limited, translating the best available information into clinical practice is important to providing quality care. In addition, conducting further research in prehospital pediatric trauma care will be vital to

providing the best care possible in the future.

be vital to providing the best care possible in the future. REFERENCES 1. Shah MN, Cushman

REFERENCES

1. Shah MN, Cushman JT, Davis CO, et al. The epidemiology of emergency medical services use by children: an analysis of the National Hospital Ambulatory Medical Care Survey. Prehosp Emerg Care 2008;12:269-76.

2. Krug S, Kuppermann N. Twenty years of emergency medical services for children: a cause for celebration and a call for action. Pediatrics 2005;115:1089-91.

3. Ramenofsky ML. Emergency medical services for children and pediatric trauma system components. J Pediatr Surg

1989;24:153-5.

4. Institute of Medicine of the National Academies. Emergency medical services: at the crossroads. Washington, DC: National Academies Press; 2006.

5. Sampalis JS, Lavoie A, Williams JI, et al. Impact of on-site care, prehospital time, and level of in-hospital care on survival in severely injured patients. J Trauma 1993;34:252-61.

6. Lerner EB, Moscati RM. The golden hour: scientific fact or medical urban legend. Acad Emerg Med 2001;8:758-60.

7. Carr BG, Caplan JM, Pryor JP, et al. A meta-analysis of prehospital care times for trauma. Prehosp Emerg Care 2006;

10:198-206.

8. American College of Surgeons. Advanced trauma life support for doctors. 8th ed. Chicago (Ill): American College of Surgeons; 2008.

9. Haller JA, Shorter N, Miller D, et al. Organization and function of a regional pediatric trauma center: does a system management improve outcome. J Trauma 1983;23:

691-6.

10. Engum SA, Mitchell MK, Scherer LR, et al. Prehospital triage in the injured pediatric patient. J Pediatr Surg 2000;35:

82-7.

11. Newgard CD, Cudnik M, Warden CR, et al. The predictive value and appropriate ranges of prehospital physiological parameters for high-risk injured children. Pediatr Emerg Care 2007;23:450-6.

12. Newgard CD, Rudser K, Atkins DL, et al. The availability and use of out-of-hospital physiologic information to identify high-risk injured children in a multisite, population-based cohort. Prehosp Emerg Care 2009;13:420-31.

13. Trunkey DD. Is ALS necessary for pre-hospital trauma care. J Trauma 1984;24:86-7.

14. Lewis FR. Ineffective therapy and delayed transport. Prehosp Disaster Med 1989;4:129-30.

15. Ornato JP, Racht EM, Fitch JJ, et al. The need for ALS in urban and suburban EMS systems. Ann Emerg Med 1990;19:1469-70.

16. Carr BG, Brachet T, Guy D, et al. The time cost of prehospital intubations and intravenous access in trauma patients. Prehosp Emerg Care 2008;12:327-32.

17. Liberman M, Mulder D, Sampalis J. Advanced or basic life support for trauma: meta-analysis and critical review of the literature. J Trauma 2000;49:584-99.

18. Suominen P, Baillie C, Kivioja A, et al. Prehospital care and survival of pediatric patients with blunt trauma. J Pediatr Surg 1998;33:1388-92.

19. Cudnik MT, Newgard CD, Wang H, et al. Endotracheal intubation increases out-of-hospital time in trauma patients. Prehosp Emerg Care 2007;11:224-9.

20. Cudnik MT, Newgard CD, Wang H, et al. Distance impacts mortality in trauma patients with an intubation attempt. Prehosp Emerg Care 2008;12:459-66.

21. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of- hospital pediatric endotracheal intubation on survival and neurologic outcome. JAMA 2000;283:783-90.

22. Ehrlich PF, Seidman PS, Atallah O, et al. Endotracheal intubations in rural pediatriac trauma patients. J Pediatr Surg

2004;39:1376-80.

23. Lillis KA, Jaffe DM. Prehospital intravenous access in children. Ann Emerg Med 1992;21:1430-4.

24. Fuchs S, LaCovey D, Paris P. A prehospital model of intraosseous infusion. Ann Emerg Med 1991;20:371-4.

25. Guy J, Haley K, Zuspan SJ. Use of intraosseous infusion in the pediatric trauma patient. J Pediatr Surg 1993;28:158-61.

26. Wears RL, Winton CN. Load and go versus stay and play:

analysis of prehospital IV fluid therapy by computer simulation. Ann Emerg Med 1990;19:163-8.

27. Teach SJ, Antosia RE, Lund DP, et al. Prehospital fluid therapy in pediatric trauma patients. Pediatr Emerg Care

1995;11:5-8.

28. Sadow KB, Teach SJ. Prehospital intravenous fluid therapy in the pediatric trauma patient. Clin Pediatr Emerg Med 2001;2:

23-7.

29. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000;343:94-9.

30. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;180:e20.

31. Atabaki SM. Prehospital evaluation and management of traumatic brain injury in children. Clin Pediatr Emerg Med

2006;7:94-104.

32. Covassin T, Swanik CB, Sachs ML. Epidemiological con- siderations of concussions among intercollegiate athletes. Appl Neuropsychol 2003;10:12-22.

PREHOSPITAL MANAGEMENT OF PEDIATRIC TRAUMA / SHAH VOL. 11, NO. 1 17

33. NCCSIR. Eighteenth Annual Report, Fall 1982-Spring 2000. Chapel Hill (NC): University of North Carolina; 2000.

34. Baxt WB, Moody P. The impact of advanced prehospital care on the mortality of severely brain-injured patients. J Trauma

1987;27:365-9.

35. Badjatia N, Carney N, Crocco TJ, et al. Guidelines for prehospital management of traumatic brain injury, 2nd ed. Prehosp Emer Care 2007;12:S1-S52.

36. Kuppermann N, Holmes JF, Dayan PS, for the Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically- important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374:1160-70.

37. Cantu R, Voy R. Second impact syndrome: a risk in any sport. Phys Sport Med 1995;23:27-36.

38. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the First International Symposium on Concus- sion in Sport. Vienna 2001. Phys Sport Med 2002;30:57-63.

39. Collins M, Stump J, Lovell MR. New developments in the management of sports concussion. Curr Opin Orthop 2004;

15:100-7.

40. Izsak E, Moore JL, Stringfellow K, et al. Prehospital pain assessment in pediatric trauma. Prehosp Emerg Care 2008;12:

182-6.

41. Baxt C, Kassam-Adams N, Nance M, et al. Assessment of pain after injury in the pediatric patient: child and parent perceptions. J Pediatr Surg 2004;39:979-83.

42. Zempsky WT, Cravero JP. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics

2004;114:1348-56.

Abstract:

Laboratory studies are often routi- nely obtained in the injured child. How broad a range of studies are needed and do they impact on the child's management? This article reviews the literature and makes recommendations for a simplified, cost-effective laboratory testing strategy.

Keywords:

pediatric trauma; laboratory studies; intraabdominal injury

Reprint requests and correspondence:

Jeffrey F. Linzer Sr MD, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, GA

30322.

1522-8401/$ - see front matter © 2010 Elsevier Inc. All rights reserved.

Do Routine Laboratory Tests Add to the Care of the Pediatric Trauma Patient?

Jeffrey F. Linzer Sr, MD

L aboratory tests are often obtained on children who have had traumatic injuries. These tests range from a complete blood count (CBC) to serum chemistries, liver and pancreatic enzymes, coagulation studies, and

urinalysis (UA). The primary purpose for obtaining these tests in the emergency department is either to (1) manage and monitor the unstable patient or (2) screen the stable patient to determine the need for imaging studies. In some circumstances, the indication for specific testing is straightforward. For example, a type and cross match for blood would be indicated for the hemodynamically unstable patient. The decision to provide additional treatment or to obtain a computerized tomographic (CT) study is often based on clinical evaluation and is made before these laboratory results are made available. 1,2

It is the patient who has had blunt trauma without obvious injury, however, where the use of routine laboratory testing comes into question. Screening laboratory tests are most often used in these patients to determine the need for CT imaging. As there is now greater recognition of the potential risks from ionizing radiation, especially in younger children, the question of the use of laboratory testing to determine who needs imaging has become a larger issue. A review of the literature shows that there is no simple answer as to what test(s) may be of benefit. The routine use of trauma panels in pediatric trauma victims does not appear to provide any significant clinical benefit. 1-5

LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER VOL. 11, NO. 1 19

URINALYSIS

Although no test has been shown to be 100% sensitive and specific, the UA appears to have some use in determining the presence of intraabdominal injury (IAI) in blunt trauma. There is controversy, however, as to the quantity of blood that needs to be present to determine the need for a CT scan. In adults who are not hypotensive and who have not had a deceleration entry, imaging is only indicated if there is frank hematuria. In a retrospective study by Quinlan and Gear- hart, 6 frank hematuria along with a low hematocrit correlated with severe renal injury. In a review by Stein et al, 7 any degree of hematuria was an indication for radiographic imaging. Isaacman and colleagues 8 found that there was a low prevalence of laboratory abnormalities in children with mild to moderate trauma. Using a cutoff of greater than 5 red blood cells per high-power field (RBC/hpf), they found the physical examination, in a patient with a Glasgow Coma Score (GCS) of 12 or higher, along with the UA, had a sensitivity of 100%, specificity of 64%, and a negative predictive value of 100% for IAI. 8 In a prospective study of children with blunt trauma, Holmes et al 9 also found an association of IAI with a UA with more than 5 RBC/hpf (odds ratio, 4.8; 95% confidence interval [CI], 2.7-8.4). Taylor et al 10 found an association between abdominal symptoms and a UA with greater than 10 RBC/hpf, but noted that asymptomatic hematu- ria would have a low yield as an indicator for CT of the abdomen. Whereas Lieu and colleagues 11 found that more than 20 RBC/hpf was associated with higher yield intravenous pyelography, Abou-Jaoude et al 12 found that using that same value missed 28% of genitourinary tract injuries or anomalies. Both groups of investigators believed that clinical judg- ment was valuable in determining the need for radiographic imaging. Several studies, however, have shown that a baseline of 50 RBC/hpf can be used to determine the need for acute radiographic imaging to evaluate for renal injury. Morey 13 found that a CT scan was not indicated in patients with minor abdominal trauma if there were less than 50 RBC/hpf. The likelihood of significant genitourinary injuries was 2% in that group of patients. Perez-Brayfield et al 14 also found that a CT was indicated in children with more than 50 RBC/hpf, who were hypotensive or had had a significant mechanism of injury (eg, high- speed deceleration injury). Stalker and colleagues 15 found a direct relationship between the severity of renal injury and the degree of hematuria in that the higher the grade of injury the more RBCs that were

seen in the UA. In that same study, children with blunt abdominal trauma who were not in shock and had less than 50 RBC/hpf did not benefit from radiographic imaging.

HEMATOLOGY

A CBC, on the whole, provides little predictive

information regarding the trauma patient. White blood cell elevation is often encountered, usually due to the stress of the injury. 3 However, there is no correlation between elevation and the degree of injury. In one study, 1% of patients had platelet counts less than 100 000/hpf, but none required

platelet transfusions. 1 Monitoring platelet counts in hemodynamically unstable patients, especially those who are receiving massive transfusions, may be of value.

A low initial hematocrit may warn of ongoing

hemorrhage from an occult bleed. Holmes et al 9 found an initial value of less than 30% to be a predictor of IAI, whereas Cotton et al 5 found each unit decrease resulted in an 11% increase risk for IAI. Although a low hematocrit may imply the need for transfusion, patients will usually have signs of hemodynamic instability such as tachycardia or hypotension. 1 One must however keep in mind that hypotension is a late sign of shock in children. Serial hematocrits may help in the monitoring of solid organ injuries.

SERUM CHEMISTRIES

Liver transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) are often used as a screen for liver injury. Using recursive partitioning retrospective analysis, Cotton et al 5 found that 88% of patients with IAI were correctly identified when they had an AST more than 131 U/L with a hematocrit of less than 39% (sensitivity 100% [95% CI, 90%-100%] and specificity of 87% [95% CI, 83%-91%]). An ALT of more than 105 U/L had similar findings. As other solid organ injury, such as kidney and pancreas, can also produce elevated transaminases, Chu et al 16 found that a higher value, AST of more than 200 U/L or ALT of more than 125 U/L, were predictors of liver injury. Holmes et al 9,17 also identified these elevated values as among the high-risk variables used in the decision to image children for IAI. Keller and colleagues 1 found that children with elevated transaminases were more likely to have liver injury compared to children with normal levels (elevated vs normal: AST 12% vs 0%, ALT 17% vs 0%; P b .05). However, he determined that only levels of

20

VOL. 11, NO. 1 LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER

more than 400 U/L were predictive of liver injury. Because these levels were associated with patients who had other indications for imaging (eg, physical examination), the value did not influence the decision for imaging studies or other interventions. In a review of various trauma panel studies, Capraro et al 3 did not find either the AST or ALT to be of any value in predicting IAI or in determining the need for CT imaging. They found that AST had a sensitivity of 63% (95% CI, 51%-74%), a negative predictive value of 71% (95% CI, 67%-82%), and a positive predictive value of 38% (95% CI, 29%-47%). Alanine aminotransaminase fared no better with a sensitivity of 52% (95% CI, 41%-64%), a negative predictive value of 75% (95% CI, 67%-82%), and a positive predictive value of 48% (95% CI 37-60%). In the study by Isaacman et al, 8 elevated AST and ALT levels did not make a significant contribution in predicting the presence of IAI or in determining the need for imaging. The use of serum amylase and lipase for screening of pancreatic injury in children appears to carry little use. Adamson et al 18 found that although these values were elevated in pancreatic injury, there was no cost-benefit in using them as screening tests to determine the need for CT scanning. Simon et al 19 found that pancreatic enzyme screening was of limited value in the initial assessment of blunt abdominal trauma. In addition, Namias et al 2 did not find any correlation between serum amylase eleva- tion and pancreatic injury. Serum electrolytes also contribute very little in the evaluation of the hemodynamically stable patient. Although transient abnormalities may occur, they are not usually clinically relevant and do not impact management. 2,4,8

COAGULATION STUDIES

Coagulopathy has been shown to be associated with significant head injuries 20 and is a predictor of poor outcome. 21,22 In a meta-analysis, Harhangi and colleagues 23 found that 1 in 3 patients with traumatic brain injury was at risk for developing a coagulopathy and that the presence abnormal coagulation studies was an independent predictor of prognosis (odds ratio of mortality 9.0 [95% CI, 7.3-11.6] and unfavorable outcome 36.3 [95% CI, 18.7-70.7]). Keller et al 24 found that children with a GCS of less than 14 after traumatic brain injury appeared to be at the greatest risk of developing a coagulopathy (7% for a GCS of 15 vs 67% for GCS 14; P b .05). Keller et al 24 also found an inverse relationship between decreasing GCS and the risk of coagulopathy.

When compared to other coagulation studies (activated partial thromboplastin time [PTT], thrombin time, bleeding time, platelet count, fibrinogen, fibrin degradation products, and hemat- ocrit), Hymel et al 20 found that prolongation of the prothrombin time (PT) was associated with paren- chymal brain injury. In the review by Vavilala et al, 22 a fibrin degradation product of more than 1000 μ g/mL was associated with a poor outcome in children with a GCS between 7 and 12. Holmes and colleagues 25 ascertained that chil- dren with a GCS of 13 or lower had an odds ratio of 8.7 (95% CI, 4.3-17.7) of having an elevated international normalized ratio (INR) of 1.5 or higher or a PTT of 40 seconds or more. Keller et al 24 used PT, INR, and PTT in finding that 43% of the children in his review with intracranial injuries had coagu- lation abnormalities.

COST

Based on the Centers for Medicare and Medicaid Services 2009 median for laboratory test code fee schedules (Table 1), a traditionaltrauma panel consisting of a CBC, comprehensive metabolic profile, amylase, lipase, PT (including INR), PTT, and UA (with microscopy) would cost $84.45. 26 Hematocrit, AST, and UA would cost $21.12, whereas hematocrit and UA alone would cost $10.92.

SUMMARY AND RECOMMENDATIONS

In the unstable trauma patient, hematocrit, type and cross match, PT, INR, and PTT are useful tests in managing the critically injured patient. Transa- minases, pancreatic enzymes, and UA are not

TABLE 1. Laboratory charges.

CBC without differential Hematocrit Basic metabolic profile Comprehensive metabolic profile Hepatic function profile AST ALT Amylase Lipase PT PTT Urinalysis (dip) UA (automated with microbiology)

$12.77

$4.67

$16.70

$20.86

$16.12

$10.20

$10.44

$12.79

$13.59

$7.75

$11.84

$6.25

$6.25

Based on midpoint values published by Centers for Medicare and Medicaid Services, revised January 2009. 26

LABORATORY TESTS IN PEDIATRIC TRAUMA CARE / LINZER VOL. 11, NO. 1 21

necessary in determining the need for a CT scan because imaging decisions are typically based on the physical status of the patient. Holding blood for later use (eg, blood samples obtained during vascular access) if the CT scan shows liver or pancreatic injury is cost-effective and does not adversely affect patient management. 27 In the hemodynamically stable child, no laboratory tests are needed to determine the need for radiographic imaging if there are any physical findings of abdominal injury, including tenderness and contusion, or a positive Focused Assessment by Sonography in Trauma (FAST) examination. The physical examination alone is clearly the best determinant for the need for CT imaging for IAI. 5,8,28 In the child with blunt trauma to the thorax without any physical findings and a negative FAST, a hematocrit and UA should be obtained. It is not unreasonable to obtain an AST or ALT in this scenario. Imaging is indicated if the hematocrit is less than 30%, UA has 50 RBC/hpf or more, AST is more than 200 U/L, and/or ALT is more than 125 U/ L. A pregnancy test (urine or serum) should be obtained on every female patient of reproductive potential age. Prothrombin time, INR, and PTT have demonstrated value in monitoring patients with a

GCS of less than 14.

value in monitoring patients with a GCS of less than 14. REFERENCES 1. Keller MS, Coln

REFERENCES

1. Keller MS, Coln CE, Trimble JA, et al. The utility of routine trauma laboratories in pediatric trauma resuscitations. Am J Surg 2004;188:671-8.

2. Namias N, McKenney MG, Martin LC. Utility of admission chemistry and coagulation profiles in trauma patients: a reappraisal of traditional practice. J Trauma 1996;41:21-5.

3. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care 2006;22:480-4.

4. Tasse JL, Janzen ML, Ahmed NA, et al. Screening laboratory and radiology panels for trauma patients have low utility and are not cost effective. J Trauma 2008;65:1114-6.

5. Cotton BA, Liao JG, Burd RS. The utility of clinical and laboratory data for predicting intraabdominal injury among children. J Trauma 2005;58:1306-7.

6. Quinlan D, Gearhart J. Blunt renal trauma in childhood. Features indicating severe injury. Br J Urol 1990;66:

526-31.

7. Stein J, Kaji D, Eastham J, et al. Blunt trauma in the pediatric population: indications for radiographic evaluation. Urology

1994;44:406-10.

8. Isaacman DJ, Scarfone RJ, Kost SI, et al. Utility of routine laboratory testing for detecting intra-abdominal injury in the pediatric trauma patient. Pediatrics 1993;92:691-4.

9. Holmes JF, Sokolove PE, Brant WE, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med 2002;39:500-9.

10. Taylor GA, Eichelberger MR, Potter BM. Hematuria: a marker of abdominal injury in children after blunt trauma. Ann Surg

1988;208:688-93.

11. Lieu TA, Fleisher GR, Mahboubi S, et al. Hematuria and clinical findings as indicators for intravenous pyelography in pediatric blunt renal trauma. Pediatrics 1988;82:

216-22.

12. Abou-Jaoude WA, Sugarman JM, Fallat ME, et al. Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma. J Pediatr Surg 1996;31:88-90.

13. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol 1996;156:

2014-8.

14. Perez-Brayfield MR, Gatti JM, Smith EA, et al. Blunt dramatic hematuria and children. Is a simplified algorithm justified. J Urol 2002;167:2543-7.

15. Stalker HP, Kaufman RA, Stedje K. The significance of hematuria and children after blunt abdominal trauma. Am J Roentgenol 1990;154:569-71.

16. Chu FY, Lin HJ, Guo HR, et al. A reliable screening test to predict liver injury in pediatric blunt torso trauma. Eur J Trauma Emerg Surg 2009; doi:10.1007/s00068-009-

17. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54:

528-33.

18. Adamson WT, Hebra A, Thomas PB, et al. Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma. J Pediatr Surg 2003;38:

354-7.

19. Simon HK, Muehlberg A, Linakis JG. Serum amylase determinations in pediatric patients presenting to the ED with acute abdominal pain or trauma. Am J Emerg Med 1994;

12:292-5.

20. Hymel KP, Abshire TC, Luckey DW, et al. Coagulopathy in pediatric abusive head trauma. Pediatrics 1997;99:

371-5.

21. Miner ME, Kaufman HH, Graham SH, et al. Disseminated intravascular coagulation fibrinolytic syndrome following head injury in children: frequency and prognostic implica- tions. J Pediatr 1982;100:687-91.

22. Vavilala MS, Dunbar PJ, Rivara FP, et al. Coagulopathy predicts poor outcome following head injury in children less than 16 years of age. J Neurosurg Anesth 2001;13:

13-8.

23. Harhangi BS, Kompanje EJ, Leebeek FW, et al. Coagulation disorders after traumatic brain injury. Acta Neurochir 2008;

150:165-75.

24. Keller MS, Fendya DG, Weber TR. Glasgow Coma Scale predicts coagulopathy in pediatric trauma patients. Semin Pediatr Surg 2001;10:12-6.

25. Holmes JF, Goodwin HC, Land C, et al. Coagulation testing in pediatric blunt trauma patients. Pediatr Emerg Care 2001;17:324-8.

26. Centers for Medicare and Medicaid Services. Medicare clinical laboratory fee schedule (09CLAB.Zip). Available at:

asp#TopOfPage . Accessed October 12, 2009.

27. Bryant MS, Tepas JJ, Talbert JL, et al. Impact of emergency room laboratory studies on the ultimate triage and disposi- tion of the injured child. Am Surg 1988;54:209-11.

28. Miller D, Garza J, Tuggle D, et al. Physical examination as a reliable tool to predict intra-abdominal injuries in brain- injured children. Am J Surg 2006;192:738-42.

Abstract:

With the introduction of faster computerized tomography (CT), this radiographic modality has become widely used for the evaluation of the pediatric trauma patient. There is a substantially increased dose of ionizing radiation associated with CT compared to plain radiography. Multiple studies have demonstrated that the younger the patient at the time of exposure, the higher the radiation dose to the organs. Higher organ radiation doses have been linked with an increased cancer risk. The indiscriminate use of CT in the evaluation of the pediatric trauma patient is therefore associated with an increased risk for cancer in this population. This article's objective is to review the relative risks and benefits associated with this radiographic modality.

Keywords:

CT scan; pediatric trauma; radiation risk

Reprint requests and correspondence:

Ricardo R. Jiménez, MD, Pediatric Emergency Medicine Attending, University of South Florida Affiliated Faculty, All Children's Hospital, 801 6th St South, Saint Petersburg, FL 33701. ricardo.jimenez@allkids.org

1522-8401/$ - see front matter © 2010 Elsevier Inc. All rights reserved.

Radiographic Evaluation of the Pediatric Trauma Patient and Ionizing Radiation Exposure

Ricardo R. Jiménez, MD

S can them until they glow said the surgery attending on my first trauma case during my medical school surgery rotation. What he meant was that when dealing with a trauma patient, the

overuse of computerized tomography (CT) was acceptable. But what about the glow part? Trauma is a leading cause of death in the pediatric population. A systematic detailed evaluation is necessary in the management of the pediatric trauma patient. The goal of the trauma evaluation is the accurate and early identification of life- threatening injuries while ensuring the safety of the patient. A large part of the trauma evaluation is imaging, and it has revolutionized the way we practice medicine. The imaging evaluation can range from plain radiography of an injured extremity to a head, neck, and/or abdominopelvic CT scan. In the last decade, with the invention of faster CT technology and with the widespread availability of CT in most hospitals, there has been a substantial increase in its use as part of the trauma evaluation. In a recent study, the use of CT increased from 12.8%

RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ VOL. 11, NO. 1 23

to 22.4% from 1995 to 2003 in the evaluation of head trauma. 1 Furthermore, 11.2% of the CTs done in the United States were on patients 0 to 15 years of age. 2 However, radiographic evaluation is not an innocuous procedure and bears some risk. Diag- nostic radiography carries an exposure to ionizing radiation, ranging from fairly low doses in plain radiography to much higher doses with CT. Exposure to high levels of ionizing radiation is proven to increase the risk for cancer development later in life, especially leukemia, breast cancer, and thyroid cancer. Unfortunately, children are more susceptible to radiation effects than adults. 2-5 Chernobyl and Hiroshima survivor studies have demonstrated an increase cancer risk in the pediatric population when compared to adults. 6,7 Furthermore, an association has been shown with age at the time of exposure and cancer risk; the younger the patient at exposure, the higher the risk. 8 Consider this, actively replicating cell lines will have a higher risk of mutation; this risk is increased by ionizing radiation. It is important to be aware that the radiation dose to an organ is energy deposited divided by mass; therefore, the greater the mass, the lower the dose to the organ. Now, also consider that the actual dose of radiation to an organ is affected by the distance to the radiation source, for example, if an organ is proximal to the radiation source, the dose will be higher; as the source rotates and the organ is now distal and is partially shielded by body tissue, the dose to that organ will be lower. Because children are still undergoing development, they carry more replicat- ing cells lines than adults, and because children are often thinner than their adult counterparts, it is easy to understand why they have a higher risk associated with ionizing radiation exposure. In the past years, the main source of this radiation was environmental, averaging 3 mSv annually depending on where the person lives. The typical single CT radiation exposure ranges from 1 to 14 mSv. 9 With the increased use of imaging studies, medical diagnostic evaluation has become a major source with CT accounting for 67% of the diagnostic radiation exposure. 2 Computed tomography has become for many the imaging study of choice in the evaluation of the pediatric trauma patient, taking the place of plain radiography in the evaluation of head and neck injuries and peritoneal lavage in the evaluation on abdominal injuries. Although other modalities such as ultrasound and magnetic resonance imaging carry no ionizing radiation exposure, their use in the evaluation of the pediatric trauma patient remains unclear.

Recently, there has been increased concern regarding the association of diagnostic radiation exposure and the risk for cancer. With the increased use of CT in the care of children, we have to ask if this risk outweighs the benefits and consider short- term benefits vs long-term effects. Lastly, is it really necessary to scan them until they glow?

HEAD INJURY EVALUATION

Trauma is a leading cause of death in the pediatric population, and head trauma is the most common reason for death or disability. 10 According to the Center for Disease Control and Prevention, there are roughly 650 000 hospital visits, 3000 deaths, and 50 000 hospitalizations associated with head inju- ries. 11 Most head injuries are classified as mild. In the absence of validated clinical criteria that can identify with 100% sensitivity those patients with intracranial injury (ICI), the trauma physician often relies on imaging studies to assess the extent of the head injury. Initially, skull radiography was used to detect fractures after a head injury, followed with a CT if the x-ray detected a fracture. The presence of skull fractures in a skull radiograph is one of the stronger predictors of ICI. 12 Skull x-rays have a sensitivity of 65% and 83% negative predictive value and are better for detecting horizontal fractures that the CT can miss. Unfortunately, skull x-rays cannot detect underlining brain injury. Head CT has become the test of choice for the evaluation of head injury, especially since the introduction of helical CT, which is much faster and minimizes the need for sedation. Computed tomography is clearly a better tool for the evaluation of head injury, as it detects not only skull fractures but also ICI. Of course, it carries a higher level of ionizing radiation exposure and an increase in cancer risk. In the absence of a set of validated criteria that could reliably identify those patients with very low risk for ICI, the use of head CT has increased dramatically for the past decade. The problem lies in the overuse of CT in those head injured patients who have a very low risk for ICI, which some studies suggest range from 40% to 60% of patients with head trauma. 13-16 When comparing ionizing radiation exposure associated with skull x- rays vs CT, there is a noticeable difference with doses from plain radiographs ranging from 0.02 to 10 mGy and doses from CT ranging from 5 to 20 mGy. 5 To put this in perspective, we should remember that the annual background radiation exposure in the United States averages 3 mSv and that 1 mSv = 1 mGy. 9 Therefore, radiation exposure

24

VOL. 11, NO. 1 RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ

associated with head CT is not only higher but is also additive to background radiation. Brenner and colleagues 3,4 have estimated organ doses associated with CT use; the dose is dependent on the actual milliampere setting used in the scanner. The relationship between dose and milli- ampere is linear. When the setting used was 200 mAs, the organ radiation dose to the brain from one head CT ranged from 15 to 65 mGy; the highest dose was associated with the youngest patients. The organ dose remained the same after 15 years of age and increased directly proportional to decreasing patient age. Conversely, in a study by Jimenez et al 17 where anthropomorphic phantoms were used to quantify the organ doses after head and neck CT, the pituitary organ radiation dose in the 1-year-old phantom was 21.25 mGy, whereas in the 5-year-old phantom, it was 33.8 mGy. It is important to recognize that there are data supporting an increase in individual cancer risk with these dose ranges. 18 Brenner 3 was able to extrapolate a lifetime attributable cancer risk associated to the organ doses from a single head CT. The attributable risk was estimated to be highest in those younger than 2 years, with a one in 2000 risk for the development of cancer associated with a single head CT. It is important to understand that radiation doses are cumulative and will increase with the number of exposures, and also, the attributable risk is a function of the scanner setting used (in this case 200 mAs). When evaluating for the pediatric trauma victim for head injury, we need to ask if the diagnostic benefits of CT imaging outweigh the radiation risk. For those children with a mechanism of injury or clinical findings indicative of a higher risk for ICI, the answer is yes. As discussed earlier, 40% to 60% of the children who receive a CT as part of the head injury evaluation are considered minor trauma, and only about 10% of these children will have a positive finding. This large discrepancy in the large number of CTs and the small number of positive findings in children with minor head trauma is associated with the lack of validated criteria that will identify patients with a very low risk for ICI. Recent data obtained by the Pediatric Emergency Care Applied Research Network (PECARN) presented a very promising prediction rule for identifying children at very low risk of ICI. This prospective cohort study analyzed more than 42 000 children with minor head injury dividing them in 2 groups, younger than 2 years and 2 to 18 years of age. PECARN investigators used a prediction rule to identify those with very low risk for ICI. For those younger than 2 years, the rule included normal mental status, no scalp hematoma except

frontal, no loss of consciousness or loss of conscious- ness less than 5 seconds, nonsevere injury mecha- nism, no palpable skull fracture, and acting normally as per parents. In the 2 to 18 years group, this decision rule included normal mental status, no loss of consciousness, no vomiting, no severe headache, nonsevere injury mechanism, and no signs of basilar skull fracture. The younger-than-2-year-old rule had

a negative predictive value and sensitivity of 100%

and the 2- to 18-year-old rule had a negative predictive value of 99.95% and sensitivity of 96.8%. 19 This is the largest and most comprehensive study evaluating minor head injury. The study was able to validate a prediction rule that would serve to identify those children at very low risk of ICI and those for whom a head CT may be obviated for the trauma evaluation as the risk for ionizing radiation will outweigh the benefits.

NECK INJURY EVALUATION

The evaluation of the cervical spine for cervical spine injury (CSI) is an integral part of the pediatric trauma patient evaluation. Cervical spine injuries can have severe deleterious effects if left untreated, from permanent neurologic defects to death. Be- cause CSIs are very hard to evaluate clinically, radiographic evaluation has been an integral part of the traumatic cervical spine evaluation. Conven- tional 3-view (anteroposterior, lateral, odontoid) cervical spine plain radiographs are a standard part of the neck injury evaluation. Both adult and pediatric literature supports the use of neck CT for the evaluation of CSI as it yields a higher detection rate and is more cost-effective. 20-23 Cervical CT alone has been shown to have a sensitivity of 98% for CSIs; in contrast, conventional radiography has been shown to miss up to 57% of CSIs. 24,25 Keenan

et al 22 and Blackmore et al 23 both support the use of

cervical CT for the evaluation of high-risk patients, which include altered mental status or focal neurologic deficit. An increase in the use of CT and its use without the use of plain radiography has been noted in the evaluation of CSIs. 19,26

The adult literature recommendations for clear- ing the cervical spine after a traumatic injury seem to agree that those patients classified as high risk should be evaluated with a cervical spine CT. The most common criteria used in the adult literature to classify a patient as high risk are focal neurologic deficit and altered mental status. A pediatric literature review by Slack and Clancy 27 suggested

a similar approach in clearing the cervical spine in

children as that in adults. Cervical spine injuries are rare in the pediatric trauma patient. The largest

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study evaluating CSI in the pediatric population, The National Emergency X-ray Utilization Study (NEXUS) group, 28 found a CSI incidence rate of 0.98% in the pediatric population compared to 2.54% in adults. The difference in prevalence of CSI between the pediatric and adult population is probably associated with the anatomical and phys- iologic differences that exist among them. These differences are more prominent in those younger than 8 years but persistent in those 8 to 12 years. 29,30 The NEXUS decision rule has been shown to be 100% sensitive in the detection of CSI in the pediatric population. The decision rule used by the NEXUS group includes changes in sensorium,

intoxication, focal neurologic deficits, distraction injury, and midline cervical tenderness. With the low incidence of CSI in the pediatric population and

a decision rule that can potentially identify those

pediatric patients at lower risk, is there a need to use CT as a screening tool to clear the cervical spine and

if so what is the risk?

Once again, the risk has to be measured against the benefits. It has already been established that there is a substantial increase in ionizing radiation exposure associated with CT use. Jimenez et al 17

studied the amount of radiation exposure between plain neck radiography and neck CT using anthro- pomorphic phantoms representing a 1-year-old and

a 5-year-old. This study directly collected the dose

received by certain organs in the neck, specifically the thyroid which is recognized as one of the most radiosensitive organs in the body. Jimenez and

colleagues 17 found that in the 1-year phantom, the radiation received to the thyroid from a CT was 385 times (59.28 mGy) that from a 3-view neck x- ray, and in the 5-year phantom, the neck CT provided a dose 164 times greater (52.3 mGy) than that from conventional radiography. 19 Again, it appears that the younger the patient, the higher the radiation organ dose. Interestingly enough, Jimenez et al 17 also found that the organ dose to the thyroid from a head CT was higher than that of

a 3-view conventional neck x-ray, which is concer-

ning as some patients receive both a head and neck CT as part of the trauma evaluation. 19 Brenner 3,4 has also confirmed that the organs that receive most of the radiation secondary to a head CT are the brain and thyroid. Studies about Chernobyl and Hiroshima survivors have reported an increase in thyroid cancer in the pediatric population with a significant linear asso- ciation between radiation dose and cancer risk. 6,7,31

Furthermore, Ron 32 reported that the age at time of exposure was strongly linked to the risk for thyroid cancer, with those younger than 15 years having the

strongest association. 33 With the increased use of CT for the evaluation of neck injury, it is important to evaluate the risk for thyroid cancer later in life for those patients who are exposed. In the study by Jimenez et al, 17 the excess relative risk for thyroid cancer was calculated. Those younger than 5 years appear to have a higher risk of developing thyroid cancer, with those younger than 1 year doubling their cancer risk with only one CT. 19

ABDOMINAL EVALUATION

Blunt trauma accounts for 90% of childhood injuries, and although only 10% of these injuries involve the abdomen, abdominal injuries are one of those most commonly missed. 33 The general ap- proach for the evaluation of pediatric blunt abdom- inal trauma is based upon the clinical status of the patient. Abdominal CT is well accepted as the standard diagnostic tool for the evaluation of abdominal injuries. This would signify that most children evaluated for intra-abdominal injuries will undergo a CT, which of course is associated with radiation exposure to the abdominal organs. Recent- ly, a prediction rule for the identification of children with intra-abdominal injury has been validated; it showed good sensitivity but was unable to identify 100% of the children with intra-abdominal inju- ry. 34,35 In this same study, the authors estimated that when these 6 high-risk variable prediction rules were used appropriately, it would decrease the number of abdominal CTs by one third. 34,35 Brenner 3,4 evaluated the radiation exposure associated with an abdominal CT and found that the organs that were most affected were the liver and the stomach. The doses ranged between 12 and 25 mGy at 200 mAs. Once again, this relation is linear and can be scaled up or down depending on the mAs used in a specific scanner/examination. The relationship between organ radiation dose and age were again inversely proportional, putting the youngest children at highest risk. When the esti- mated risk for developing cancer was calculated, the digestive organs were the most affected, and the cancer risk increased as the age at exposure decreased. The estimated lifetime risk was found to be small, ranging from 1/2000 to 1/1000 in the youngest patients. 3,4 In the last decade, the use of focused assessment with sonography for trauma (FAST) by emergency physicians for the evaluation for abdominal trauma of the adult patient has become more accepted. The use of FAST has been shown to shorten the time to the operating room in the unstable trauma pa- tient. 35,36 The American College of Emergency

26

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Physician has issued guidelines that strongly en- courage the availability and use of FAST in the evaluation of the trauma patient. 36,37 It is under- standable that FAST could decrease the use of abdominal CT, reducing the organ radiation expo- sure. However, the use of FAST for the evaluation of the pediatric trauma patient has not been widely accepted, and there are no clear guidelines for its use in children. The reported sensitivity of FAST in the pediatric population ranges from 31% to 100%, and it appears to perform well in the detection of free fluid in the hypotensive patient. 37-39 More studies are needed that support the use of FAST in the pediatric trauma patient before guidelines can be devised for its regular implementation in the pediatric population. This is a tool that will hopefully help reduce the use of abdominal CT, thus, reducing the risk for cancer.

SUMMARY

Computed tomography has become one of the most frequently used diagnostic tools in the evalua- tion of the pediatric trauma patient. There is an inherent risk associated with ionizing radiation exposure secondary to CT use, and children are more susceptible than adults to the development of radiation-induced cancer. Although the risk may be low and the benefits may greatly outweigh the risk in certain cases, such as those children with more severe injuries, it is important to weigh the risk vs the benefit for every patient. Exposing a child to a radiation dose that increases the risk for cancer without a proven diagnostic advantage is no longer acceptable. This practice is also contrary to ALARA (as low as reasonably achievable) that acknowledges that no level of diagnostic radiation is without risks. Scan them until they glow violates the ALARA concept and is not an appropriate approach to the

evaluation of the pediatric trauma patient.

approach to the evaluation of the pediatric trauma patient. REFERENCES 1. Blackwell CD, Gorelick M, Holmes

REFERENCES

1. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changes in use of computed tomography in emer- gency departments in the United States over time. Ann Emerg Med 2007;49:320-4.

2. Mettler FA, Wiest PW, Locken JA, et al. CT scanning: patterns of use and dose. [see comment] J Radiation Protect 2000;20:

353-9.

3. Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol 2002; 32:223-8 [discussion 242-224].

4. Brenner D, Elliston C, Hall E, et al. Estimated risks of radiation-induced fatal cancer from pediatric CT. [See comment] AJR Am J Roentgenol 2001;176:289-96.

5.

Health risks from exposure to low levels of ionizing radiation:

BEIR VII Phase 2. Washington, DC: The National Academic Press; 2001.

6.

American Academy of Pediatrics Committee on Environ- mental Health. Risk of ionizing radiation exposure to children: a subject review. Pediatrics 1998;101(4 Pt 1):717-9.

7.

Kazakov VS, Demidchik EP, Astakhova LN. Thyroid cancer after Chernobyl. Nature 1992;359:21.

8.

Hernandez JA, Chupik C, Swischuk LE. Cervical spine trauma in children under 5 years: productivity of CT. Emerg Radiol 2004;10:176-8.

9.

Ionization radiation exposure of the population of the United States. Report no. 93: National Council on Radiation Protection and Measurements. Bethesda (Md): National Council on Radiation Protection and Measurements; 1987.

10.

National Center For Injury Prevention and Control. Trau- matic Brain Injury in the United States: a report to Congress. Atlanta (Ga): Center for Disease Control and Prevention;

1999.

11.

Centers for Disease Control and Prevention. 2000 National Ambulatory Medical Care Survey, Emergency Department File 2002. Hyattsville (Md): National Center for Health Statistics; 2002.

12.

Schutzman SA, Barnes P, Duhaime AC. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines. Pediat- rics 2001;107:983-93.

13.

Dunnings J, Daly JP, Lomas JP, et al. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child 2006;91:885-91.

14.

Greenes DS, Schuztman SA. Clinical indicators of intracra- nial injury in head-injured infants. Pediatrics 1999;104:

861-2.

15.

Palchak MJ, Holmes JF, Vance GW, et al. A decision rule for identifying children at low risk for low brain injuries after blunt head trauma. Ann Emerg Med 2003;43:493-506.

16.

Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testing for acute head injury in children: when are computed tomography and skull radiographs indicated. Pediatrics

1997;99:1-8.

17.

Jimenez RR, DeGuzman MA, Shiran S, et al. CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks. Pediatr Radiol 2008;

38:635-44.

18.

Pierce DA, Shimizu Y, Preston DL, et al. Studies of the mortality of atomic bomb survivors. Report 12, part 1. Cancer: 1950-1990. Radiol Res 1996;146:1-27.

19.

Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injures after head trauma: a prospective cohort study. Lancet 2009;

374:1160-70.

20.

Nuñez DB, Zuluaga A, Fuentes-Bernardo DA, et al. Cervical spine trauma: how much more do we learn by routinely using helical CT. Radiographics 1996;16:1307-18.

21.

Nuñez DB, Quencer RM. The role of helical CT in the assessment of cervical spine injuries. AJR Am J Roentgenol

1998;171:951-7.

22.

Keenan HT, Hollingshead MC, Chung CJ, et al. Using CT of the cervical spine for early evaluation of pediatric patients with head trauma. AJR Am J Roentgenol 2001;

177:1405-9.

23.

Blackmore CC, Ramsey SD, Mann FA, et al. Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis. Radiology 1999;212:117-25.

RADIOGRAPHIC EVALUATION AND IONIZING RADIATION EXPOSURE / JIMÉNEZ VOL. 11, NO. 1 27

24. Borock EC, Sheryl GA, Lenworth MJ, et al. A prospective analysis of a two-year experience using computed tomogra- phy as an adjunct for cervical spine clearance. J Trauma

1991;31:1001-6.

25. Nuñez BA, Adel A. Clearing the cervical spine in multiple trauma victim: a time-effective protocol using helical computed tomography. Am Soc Emerg Radiol 1994;1:273-7.

26. Shiran S, Jimenez R, Altman D, et al. Evaluation of C-spine HRCT. Pediatr Radiol 2005 [abstr].

27. Slack SE, Clancy MJ. Clearing the cervical spine of paediatric trauma patients. Emerg Radiol J 2004;21:273-7.

28. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;108:e20.

29. d'Amato C. Pediatric spinal trauma: injuries in very young children. Clin Orthop Related Res 2005:34-40.

30. Fesmire FM, Luten RC. The pediatric cervical spine:

developmental anatomy and clinical aspects. J Emerg Med

1989;7:133-42.

31. Sadetzki S, Chetrit A, Lubina A, et al. Risk of thyroid cancer after childhood exposure to ionizing radiation for tinea capitis. J Cli Endocrinol Metab 2006;91:4798-804.

32. Ron E. Let's not relive the past: a review of cancer risk after diagnostic or therapeutic irradiation. Pediatr Radiol 2002;32:

739-44.

33. Saladino RA, Lund DP. Abdominal trauma. In: Fleisher GR, Ludwig S, eds. Textbook of pediatric emergency medicine, 5th ed. Philadelphia (Pa): Lippincott Williams & Wilkins; 2006. p. 1453-62.

34. Holmes JF, Mao A, Awasthi S, et al. Validation of a prediction rule for the identification of children with intra- abdominal injuries after blunt torso trauma. Ann Emerg Med 2009;54:528-33.

35. Rozycki GS, Feliciano DV, Schmidt JA. The role of surgeon- performed ultrasound in patients with possible cardiac wounds. Ann Surg 1996;223:737-46.

36. American College of Emergency Physicians. Use of ultra- sound imaging by emergency physicians. Ann Emerg Med

2001;38:470-81.

37. Ma OJ, Mateer JR. Pediatric applications. In: Price DP, Peterson MA, eds. Emergency ultrasound, 2nd ed. Columbus (Ohio): McGraw-Hill Companies; 2003. p. 464-89.

38. Mutabagani KH, Coley BD, Zumberge N. Preliminary experience with focused abdominal sonography for trauma (FAST) in children is it useful. J Pediatr Surg 1999;34:

48-52.

39. Holmes JF, Brant WE, Bond WF. Emergency department ultrasonography in the evaluation of hypotensive and normo- tensive children with blunt abdominal trauma. J Pediatr Surg

2001;36:968-73.

Abstract:

The acutely injured child poses un- ique clinical challenges in many respects. Our understanding of these unique characteristic differences and ability to care for pediatric trauma patients has greatly improved over recent decades; however, one area in pediatric trauma care continues to suffer from relative neglect in re- search and shows few signs of improvement in clinical practice: an- algesia. Studies of analgesia prac- tices continue to describe pervasive undertreatment of pain in the pedia- tric trauma patient. A growing body of evidence suggests that poorly con- trolled acute pain (oligoanalgesia) not only causes suffering but may lead to both immediate complications that worsen outcomes as well as debili- tating chronic pain syndromes that are often refractory to available treat- ments. This article will provide a review of pain in injured children with respect to its pathophysiology, clin- ical ramifications, and patterns of analgesia practices. Impediments to analgesia are examined regarding multiple providers of care for the acutely injured child including pre- hospital personnel, nurses, and phy- sicians. Finally, the article will provide analgesia recommendations with an approach to pain relief and sedation for the injured pediatric patient.

Keywords:

oligoanalgesia; pain; pediatric; trauma

Pediatrics and Emergency Medicine, Em- ory University School of Medicine, Chil- dren’s Health care of Atlanta, Atlanta, GA. Reprint requests and correspondence:

Michael Greenwald, MD, 1604 Clifton Rd NE, Atlanta, GA 30322. mgreenw@emory.edu

1522-8401/$ - see front matter © 2010 Published by Elsevier Inc.

Analgesia for the Pediatric Trauma Patient: Primum Non Nocere?

Michael Greenwald, MD

E valuating pain in the trauma patient poses unique

challenges as it may simultaneously involve both

somatic and visceral pain from a variety of origins. The

pain response is a complicated process that may evolve

from acute (normal) to chronic (maladaptive) pain with persistent or repetitive exposure to injury-provoked pain. This is true for patients of any age; however, children appear especially vulner- able to the harmful effects of oligoanalgesia. Understanding how both acute and chronic pain occurs may help us better control and prevent the pain responses that can cause harmful changes after injury. A comprehensive description of pain physiology in the pediatric trauma patients is beyond the scope of this article. Instead, we will focus on select concepts of the pain response, how the pediatric patient's response to injury and pain are unique, and how chronic pain syndromes are thought to occur. These pain- related issues include visceral vs somatic pain, the stress response, hypersensitivity vs habituation, central nervous system (CNS) plasticity, hyperalgesia, and central sensitization.

KEY CONCEPTS OF PAIN PATHOPHYSIOLOGY IN THE INJURED CHILD

Visceral vs Somatic Pain

Somatic and visceral pain systems have distinct physiologic and clinical features. Cutaneous somatic innervation is more dense and limited to a few spinal segments; therefore, cutaneous somatic pain is better localized and characterized by specific sensations. Deep somatic pain (muscles, joints) resembles visceral pain in its dull nature and poor localization. Visceral organs are innervated

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD VOL. 11, NO. 1 29

by 2 sets of nerves: vagal and spinal nerves or pelvic and spinal nerves. Most internal organs are inner- vated by the vagus nerve; however, its role in transmitting pain signals is not yet clear. Most visceral afferent fibers are thinly myelinated or unmyelinated providing a dull and difficult to describe sensation. Visceral pain has poor localiza- tion as input is typically distributed over several spinal segments. This leads to similar pain sensa- tions from nociceptive activity in unrelated organs (eg, urinary bladder and colon, gall bladder and heart). Visceral nerves receive convergent somatic input (skin, muscle) resulting in referred pain to unrelated sites (eg, retrosternal pain to the neck, cardiac ischemic pain to neck, shoulder, or jaw). The stronger emotional and autonomic reactions seen with visceral pain may reflect the involvement of the anterior cingulated gyrus, amygdala, and insular cortex. Last, visceral nociceptor activation can occur even in the absence of tissue damage (eg, functional abdominal pain). 1,2

The Stress Response

Acute pain results in a stress response that manifests in physiologic, biochemical, and behav- ioral changes associated with hemodynamic insta- bility and poor wound healing. Infants are particularly vulnerable to changes in intracranial pressures related to fluctuations in systemic vascu- lar pressures because of an immature blood brain barrier. Autonomic responses to acute pain lead to fluctuations in heart rate and blood pressure. These responses may diminish with persistent pain and are often not a reliable marker for the presence of pain. Pain is also associated with hypoventilation that may lead to hypoxia. This may explain the seemingly paradoxical effect of improving respira- tory function in critically ill patients when treating their pain with effective doses of opioids. 3,4 Persistent or severe pain is associated with elevated levels of stress hormones such as catecholamines, glucagon, growth hormone, and lactate and ketones, whereas insulin levels are suppressed. Neonatal catecholamine and metabolic responses are 3 to 5 times greater than those in adults undergoing similar types of surgery. One of the most significant clinical studies on the harmful effects of poorly controlled acute pain was reported by Anand and Hickey 5 in 1992. At the time the standard of care in anesthesia held that neonates would experience worse outcomes if provided a comparable level of anes thesia during surgery. Anand and Hickey 5 conducted a trial with neonates requiring congenital heart disease repair. The

investigators found that the control group demon- strated higher levels of stress hormones (eg, hyperglycemia, lactic acidemia), greater incidence of sepsis and disseminated intravascular coagulo- pathy, and had a 27% mortality rate. The interven- tion (medication) group had no increase in pulmonary or circulatory complications and no deaths. The results starkly contradicted prevailing wisdom at the time and were so remarkable the study was ended prematurely as it was considered too risky to continue practicing the standard of care. Finally, behavioral changes seen in patients with poorly controlled pain include crying, agitation, and sleep disturbance. In one study, children in a burn unit were found to have posttraumatic stress disorder symptoms inversely related to the amount of morphine administered 6 months prior at their initial presentation. 6 Thus, many physiologic, bio- chemical, and behavioral changes associated with poorly controlled pain are the very consequences of injury we hope to prevent and control to facilitate healing and prevent harmful outcomes.

Hypersensitivity vs Habituation

One of the clinical hallmarks of a healthy adult's response to pain is the ability to habituate. That is, with repeated or prolonged exposure to a similar stimulus, the autonomic responses tend to lessen. In contrast, younger patients tend to demonstrate just the opposite. This is classically found with the heel prick of a neonate. With repeated exposures, the infant exhibits a lower pain threshold (ie, more brisk flexor response) and autonomic lability. 7 Similarly, older children report increased perception of pain if preceded by repeated painful experiences. 8 On a conceptual level, the reason why infants may differ in a pain experience lies in the difference in understanding and processing the meaning of a painful experience. This is one of the most chal- lenging areas to explore; it is unlikely we will ever know how infants perceive a painful experience. Pain experiences have both physical and emotional components that affect the reaction. Our cognitive maturity allows us to attenuate the emotional and neurophysiologic response of a non life-threatening injury. One example is the pain from a percutaneous needle insertion. The pain experienced from trauma associated with a needle insertion is likely similar on an anatomical level in different aged individuals. The pain stimulates the same nociceptors, results in the release of similar neurotransmitters, and travels on the same neural pathways to similar areas of the brain. A healthy, mature individual should recog- nize the source of the pain as something that has a

30

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positive purpose (to improve health) and a limited duration and intensity. Even the adult with needle phobia will recognize that the pain experienced will dissipate and not recur without warning. Infants and to a lesser extent children lack this perspective. This may also help explain why the stress response to the same pain stimulus is more brisk and intense in less mature or adaptive individuals. 7 There are several possible physiologic explana- tions for this phenomenon. One of the important components of pain physiology is modulation. Pain responses are either amplified or attenuated at the level of the dorsal horn of the spinal cord through the release of excitatory and inhibitory neurotransmitters. Less mature patients have a relative deficiency of inhibitory neurotransmitters and some inhibitory neurotransmitters, such as γ -Aminobutyric acid (GABA), have an excitatory effect in the premature infant. 7 Another explanation lies at higher levels in a process known as integration. When pain signals ascend to the brain, they are distributed to multiple supraspinal centers including the reticular activat- ing system, olivary, paraventricular, and thalamic nuclei; limbic system; cingulate and postcentral gyrus; frontal and parieto-occipital areas. At these levels, the pain signal is integrated and processed. Pain is identified by its localization and character- istics. The information is matched with memories of past experiences that in turn mediate levels of arousal, attention, and sympathetic responses. In laboratory studies, less mature subjects demon- strate less inhibitory pathway activation compared to more mature subjects. It is hypothesized that recognition of nonharmful painful stimuli can aid in blunting the pain signal. This ability logically relates to experiences and age and is inherently deficient in younger patients. 9

Central Nervous System Plasticity

One of the greatest concerns regarding oligoa- nalgesia in young patients is the potential for altering the developing CNS. The plasticity of the nervous system is now recognized in all age groups but is thought to have a particularly profound impact on young children because they have rapidly developing nervous systems. Pain research- ers have demonstrated that poorly controlled and repetitive exposure to pain has a unique and lasting negative impact on the CNS of young patients and that this effect is potentially more profound with less maturity. In laboratory studies of rat pups, the repeated exposure to pain results in morphologic changes at

the site of injury and the dorsal horn of the spinal column. These changes may be temporary or long lasting. They are seen at a variety of levels including changes in protein phosphorylation, altered gene expression, loss of neurons, formation of new synapses, and loss of inhibitory interneurons. Local tissue damage in the early postnatal period results in profound and lasting sprouting of sensory nerve terminals (A & C fibers) and sprouting of neighboring dorsal root ganglia cells in the spinal cord leading to inappropriate functional connec- tions and hyperinnnervation. Clinically, these changes result in allodynia and other features of neuropathic pain. 10 Repetitive pain also appears to accelerate apo- ptosis. This refers to the pruning of unused neural pathways. Although this is a normal phenomenon during infancy, it appears to be accelerated in laboratory animals subjected to repeated painful stimuli. Finally, pain is associated with activation of N -methyl D -aspartate (NMDA) receptors located on neurons. The receptor is activated by glutamate resulting in an influx of Ca ++ and Na + activating a Ca ++ calmodulin complex. This leads to production of heat shock proteins that causes lysosome degranulation and necrosis of the nerve cell. The activation of NMDA receptors is thought to contrib- ute to the development of chronic pain syndromes. Interestingly, this process is inhibited with the administration of opioids as well as NMDA receptor antagonists such as ketamine, methadone, and nitrous oxide. 11,12 Clinical evidence of these changes is found in the association of chronic conditions with exposure to painful stimuli. Anand et al 13 described how functional abdominal pain is seen in higher rates in former premature infants who experienced frequent gastric suction ing. Studies using PET scans have revealed that the anterior cingulate cortex is particularly affected by pain. This area is associated with control of emotion and attention and may help explain why premature infants who experience more medical complications exhibit a higher rate of psychosocial disorders such as attention deficit hyperactivity disorder (ADHD) and lower academic achievement compared to matched controls. 14

Pathways to Chronic Pain: Hyperalgesia, Central Sensitization, and Sympathetically Mediated Pain

Multiple pathways are described to explain the development of chronic pain after injury. These mechanisms include hyperalgesia from local inflam- matory markers, sensitization of neurons proximal

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD VOL. 11, NO. 1 31

to and surrounding damaged nerves, and sympa- thetically mediated pain. After an injury, inflammatory mediators are re- leased that may cause the pain response to increase even in the absence of additional injury. This sensitization of nociceptors results in primary hyper- algesia at the site or injury. Primary hyperalgesia manifests clinically as a more intense pain response than expected from stimuli. Secondary hyperalgesia may develop in the area surrounding the area of injury as a result of sensitization of neurons in the CNS. This central sensitization occurs when receptors that normally conduct nonpain signals (eg, touch) now transmit pain signals. When nonpainful stimuli such as touch result in a pain response the condition is called allodynia. Clinical examples of this include the severe and diffuse pain associated with burns (light touch), pharyngitis (swallowing), arthritis (movement), and in more unusual conditions such as complex regional pain syndrome (formerly reflex sympathetic dystrophy). 15 Hyperalgesia may also result from damaged or severed nerves. Instead of a diminished pain signal, Wallerian degeneration of the severed nerve may result in sensitization of nociceptors in adjacent nerves (primary hyperalgesia) and increase sponta- neous activity of adjacent nociceptors resulting in central sensitization (secondary hyperalgesia). This paradoxical pain response manifests in the clinical syndrome of neuropathic pain. Symptoms include intense burning and electrical sensations that are often refractory to opioids in usual doses. 15 As noted above, nociceptor stimulation is often associated with a resulting increase in sympathetic activity. In some circumstances, the reaction reverses: nociceptors may develop sensitivity to catecholamines. This is known as sympathetically maintained pain. In these conditions, trauma (even seemingly trivial trauma) provokes a pain response that features not only hyperalgesia but also allody- nia. The classic example is complex regional pain syndrome that, in the pediatric patient, typically involves the lower extremity of school-age girls and is often associated wit h edema and dramatic changes in cutaneous perfusion. 15

Summary of Neurophysiologic Reponses to Pain

Pain responses appear heightened in younger patients whose CNS is more vulnerable to physiolog- ic stress. Repetitive and persistent pain is associated with morphologic changes of the nervous system at multiple levels. Analgesics have a neuroprotective effect by decreasing exhibitory neurotransmitter activity, increasing inhibitory neurotransmitters,

and stabilizing neurons. The clinical result may include a lower incidence of sepsis, metabolic acidosis, disseminated intravascular coagulopathy, and death. Given this information, it appears that pain control is important for all patients and particularly the youngest. Ironically, studies of our clinical practice reflect just the opposite.

ANALGESIC PRACTICE FOR PEDIATRIC TRAUMA PATIENTS

Most of the information available regarding pain management for pediatric trauma patients focuses on isolated injuries and burns. There are more studies addressing pai n management for adult trauma patients than for children. In general, studies on analgesia practice in medicine over the past several decades reveal pervasive patterns of apparent undertreatment. In this section, we will examine the following aspects of clinical practice. What are the patterns of analgesia for pediatric patients? What are the patterns of analgesia for trauma patients? What are some of the impediments to providing analgesia for pediatric trauma patients?

Analgesia for Children

This year marks a decade since the Joint Commission on the Accreditation of Healthcare Organizations cited inadequate analgesia as the first nondisease healthcare crisis in the United States. Its response to this problem included numerous guidelines, resources, and requirements to assess and treat pain. Despite this effort, it is unclear whether we have seen improvement in the clinical practice of pain management for children. Pain research since the 1970s describes how children are given analgesics less often than adults for similar conditions and prescribed approximate- ly 50% of the weight-based equivalent of analge- sics. 16-18 Furthermore, the milligram per kilogram dosing of analgesics is generally directly related to age, that is, younger patients receive lower milli- gram per kilogram dosing regardless of clinical situation. 19 In 1996, Broome et al 20 reported that younger children received inconsistent pain assess- ment and management and that institutional standards regarding pain control were often ig- nored. That same year, Cummings et al 21 reported on children admitted to a Canadian hospital, noting that 21% had uncontrolled pain and that children were offered analgesics less than prescribed (ie, prn medications available but not provided). Interestingly, some studies have shown that those with pediatric subspecialty training may provide less

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analgesia than their generalist counterparts. In 2004, Cimpello et al 22 described this in a review of more than 700 children with fractures seen in 3 emergency departments (EDs) for 2 years. In this study, general emergency physicians prescribed more analgesics and recommended pain treatment and advice on dis- charge more often than their pediatric emergency medicine-trained colleagues. Quinn 23 described a comparison of the use of local anesthetic for lumbar puncture in children and found an even more striking contrast between those with and without pediatric subspecialty training. In this study of children presenting to different EDs in Baltimore, 93% of children treated by those without pediatric training received local lidocaine before lumbar puncture, whereas only 4.5% of children presenting to the children's hospital ED received lidocaine. At the pediatric institution, those receiving lidocaine includ- ed 0 of 168 infants, 1 of 18 toddlers, and only 8 of 12 children older than 4 years. The treating physicians were asked whether pain was experienced to the same degree regardless of age and 51% agreed with this statement. 23 In addition to the patterns found in pediatric patients, studies of other specific demographic groups have also demonstrated patterns of oligoanalgesia. Elderly patients (N 70 years old) also receive less analgesia in the ED. 24 Analgesia research by Todd et al 25 has described significant ethnic and racial disparities in the administration of analgesia. Hispanic patients in Los Angeles with isolated long bone fractures were twice as likely to receive no analgesia compared to non-Hispanic white patients, and black patients in Atlanta were less likely to receive adequate analgesia compared with white patients. 26 Finally, patterns of sex discrimination are reported with women often receiving less analgesia than men. 27 The reasons for these patterns of disparities are difficult to elucidate but important to examine; they are addressed later in this article.

Analgesia in Trauma

Research on analgesia practice for trauma patients reveals similar patterns of undertreatment, particularly for children. Friedland et al 28 com- pared analgesia provided for 215 children present- ing to Cincinnati Children's Hospital (Ohio). Children with vaso-occlusive crisis from sickle cell disease received analgesics at 100% of visits, within 52 minutes (mean), with 78% therapeutic dosing (average), and with analgesia guidance given on discharge at 100% of visits. In comparison, children with fractures received analgesics at 31% of visits, at 1.5 hours (mean) after presentation, with 69%

therapeutic dosing, and with analgesic advice given at 74% of visits. Children with burns received analgesics even less often (26% of visits), with 70% therapeutic dosing, and with only 27% receiving analgesia instructions at discharge. 28 O'Donnell 29 found that 49% of 172 children with musculoskel- etal injuries presenting to an ED were provided analgesics. Another 2002 study noted only 50% of burn victims received adequate analgesia in EDs. 30 Neighbor et al 31 described opioid use for severely injured patients in a level I trauma center over the course of 1 year. Of more than 500 cases, only 48% received intravenous opioids within the first 3 hours with the mean time to first dose of 95 minutes. Risk factors for receiving less opioid included younger age ( b 10 years old), intubation, lower revised trauma score, or not requiring fracture manipulation. 31 Studies of prehospital care demonstrate 2 patterns. In general, prehospital personnel tend to undertreat pain in trauma patients; however, when analgesia is provided by prehospital personnel, it makes a significant difference in the time to analgesia com- pared to patients who receive their first dose of analgesia by hospital personnel. A 2000 report on prehospital analgesia in more than 1000 patients showed that only 1.5% of patients received analgesia after an extremity injury. 32 A 2002 study on trans- ports of patients with isolated lower extremity injuries showed analgesic use in just 18.3% of transports. 33 Several studies on the use of prehospital analgesia protocols for injured patients have demonstrated safety, effectiveness, and increased use of prehospital opioid analgesia. 34-38 In a 2005 review of emergency medical services (EMS) transports by 20 different EMS agencies in Michigan, analgesia was provided by EMS for 22% of children having fractures or burns; however, these children received their medications 1 hour sooner than those who had to wait for a dose provided by the ED. 39

Impediments to Analgesia

Efforts to understand the causes of oligoanalgesia have revealed a wide array of possible explanations. Influences may come from the patient, family, and society as well as the medical profession. For health care professionals, these explanations include (1) fear of masking signs of serious injury or illness, (2) fear of causing or exacerbating hemodynamic or respiratory insufficiency, (3) inadequate pain as- sessment skills or efforts, (4) lack of understanding about pain and analgesics, and (5) concerns about creating addictive behavior by providing analgesia. One of the purported reasons for withholding analgesics in the trauma patient is the belief that

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD VOL. 11, NO. 1 33

pain relief achieved by analgesics could mask symptoms of an underlying pathologic condition. The implication is that outcomes will worsen due to a delay in diagnosis and progression of symptoms. A study of 215 physicians and nurses in 9 Israeli trauma units reported that analgesics were frequent- ly (78%) withheld to assist diagnosis. 40 Most provi- ders in this study believed that analgesics should be withheld in cases of abdominal or multisystem injury; however, 75% reported that they had inade- quate knowledge about pain management. 40 Although seemingly logical, the paradigm that analgesia worsens outcomes is not substantiated in the literature. The basis for this belief may lie in part with a classic surgical text originally authored by Cope, Early Diagnosis of the Acute Abdomen . The text states that in the setting of acute abdominal pain of unclear etiology analgesia will (1) mask signs and symptoms of a surgical condition causing a (2) delay in diagnosis with resulting (3) increase morbidity and mortality. Althoug h these assertions were replicated in subsequent editions, they do not offer supporting evidence. 41 In recent years, researchers have attempted to test this assumption with respect to the patient with possible acute appendicitis. More than a half dozen studies have examined the use of morphine (typically 5-mg doses) in patients with signs of peritonitis. 42,43 None of the studies revealed a delay in diagnosis or a negative outcome attributed to the morphine. One study demonstrated improved localization of tenderness. 44 Kim et al 45 published the first pediatric study on this issue and also found no false-negative evaluations and no complications attributed to opioid used for children with an acute abdomen. Opioid use in trauma patients has received close examination in the literature. The 3 primary concerns in acute pain management are altered mental status (ie, masking disorders involving the CNS or CNS perfusion), respiratory depression, and masking seri- ous injuries by blocking the pain response. Although excessive dosing of opioids can certainly cause CNS or respiratory depression, research in clinical use of opioids in trauma patients does not support the presumption that analgesia worsens outcomes. Budu- han et al 46 studied more than 500 trauma patients and found no correlation with opioid use and missed injuries. Lazarus et al 47 reported a study of adverse drug events in more than 4000 trauma patients and found no serious events due to opioids. Finally, several large studies have demonstrated safety and efficacy of fentanyl used by EMS for trauma patients 48 including one pediatric study. 49 Improving pain assessment is a primary focus for reducing oligoanalgesia. Whipple et al 50 called atten-

tion to this issue in a 1995 study that described a striking contrast in perceptions among patients with multisystem injury in a critical care setting. Ninety- five percent of housestaff and 81% of nurses reported adequate analgesia provided for patients who simul- taneously rated pain moderate or severe 74% of the time. It is logical that improved pain assessment would lead to improved analgesia. In a 2004 prospective study of 150 adult trauma patients, 60% of those with pain scores received analgesics com- pared to 33% without pain scores. The mean time to analgesia was 68 minutes in this study. 51 However, a recent pediatric study on pain assessment failed to show a change in analgesia administration rates and time to analgesia with improved documentation of pain scores. 52 Barriers to analgesia likely occur at multiple steps beginning with pain assessment and then the response to that information.

A study of 355 ED nurses revealed deficits in

understanding pharmacologic analgesic principles and concepts such as addiction, tolerance, and dependence. 53 Scores correlated with education level and improved after a 1-day seminar. Fifty- three percent of nurses cited the potential for analgesics to mask signs of injury or illness as a

barrier to providing treatment. Forty-eight percent reported inadequate pain assessment skills. 53

In a 2004 study of prehospital personnel, Hennes

et al 54 found significant differences in the comfort level of EMS providers in administering analgesics depending on a patient's condition. Of the subjects, 93% to 95% reported feeling comfortable providing analgesics to patients with pain from fractures, burns, or nonspecific chest pain if the patient was older than 17 years. Much fewer respondents felt comfortable if similar patients were 7 to 17 years old (chest pain, 36%; extremity injury, 70%; burn, 77%) and even less if younger than 7 years (chest pain, 24%; extremity injury, 38%; burn, 44%). In this study, respondent s cited the following as barriers to providing analgesia to pediatric patients:

inability to assess pain (87%), difficult vascular access (80%), delay of transport (66%), fear of complication (68%), record keeping (30%), and possible drug seeking (65%). 54

Although attention to pain in the adult medical literature has increased exponentially in recent years, a focus on analgesia for children and trauma patients remains sparse. Much of the research in pediatric pain centers on animal models. Major pediatrics and pediatric emergency medicine texts still provide relatively little attention to pain. The advanced trauma life support course practically ignores the subject. In previous editions of the advanced trauma life support provider manual, pain

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was briefly addressed in a paragraph that followed the section on the secondary survey. 55 The most recent editionhasomitted even thisbriefmention.Theindex cites just 2 pages where pain is addressed in the current manual: as part of C-spine evaluation and under musculoskeletal trauma. In the latter section, the authors' guidance states Whenever analgesics, muscle relaxants, or sedatives are administered to an injured patient, the potential exists for respiratory arrest. 56 In comparison, the Emergency Nurses Association course, Advanced Trauma Nursing:

A Conceptual Approach, has an entire chapter on

pain in the trauma patient. 57 This contrast highlights

the differing emphasis on pain management seen in the nursing and medical professions.

RECOMMENDATIONS FOR ANALGESIA IN THE PEDIATRIC TRAUMA PATIENT

The dictum First do no harm seems to conflict with efforts to effectively control pain; but as explained in the preceding pages, there is consider- able harm inflicted by allowing pain to continue unchecked. This final section will cover select modalities for both pain and anxiety. Although

there is no panacea for traumatic pain, the treating clinician will find success with anticipation of analgesia needs, an understanding of both the patient and available treatments, and an approach

of titrating to effect.

Pain Management Approach for the Injured Child

When treating pain, physicians often tend to think only of medications ( when you have a hammer, all the world's a nail), however, effective pain man- agement relies first on the skilled use of nonphar- macologic approaches. The first key intervention is pain assessment and reassessment. Just as shock is overlooked if capillary refill, heart rate, and blood pressure measurements are neglected, untreated pain usually occurs because it is not recognized. The challenge lies not only in finding effective tools to measure pain but simply paying attention to pain in the clinical setting. Using our most validated instruments (eg, Wong- Baker Faces scale), pain assessment is generally considered to be unreliable in children younger than 3 years and the visual analog scale is generally not useful in children younger than 6 years (Table 1 ). Furthermore, acutely injured patients may require intubation and therefore lose the ability to vocalize discomfort. When a patient is unable to perform a pain score, the clinician is left with secondary assessment measures. Vocalizations such as crying,

TABLE 1. Pain assessment scales.

Patient

Recommended

Scoring

Description

Scale

Range

Infants

NIPS: Neonatal Infant Pain Scale Wong-Baker Faces Scale

0-21

Preschool

0-5

School age adolescent

Visual Analog Scale

0-10

Intubated/

noncommunicative

Comfort Scale

8-40

grunting, or moaning may reflect pain; however, children with painful injuries may make no sound simply because they fear that vocalizations will prompt an injection. Heart rate and blood pressure are often elevated in acute pain; however, hemody- namic changes are not always reliable markers in painful settings. Vagal responses to pain may decrease heart rate, whereas some patients demon- strate a more attenuated sympathetic response, particularly when pain is prolonged. When uncertain one should ask a simple rhetorical question: Is this a painful condition/situation? If so, examine the effect of a small dose of analgesia on vital signs, muscle tone, respiratory effort, and overall affect. Just as important as doing the right thingis caution not to do the wrong thing. Anxiety and pain are magnified in children when they feel a loss of control and lack psychosocial support. This, of course, is also true for adults; the difference lies in the ability to recognize and express these feelings. How we speak with vulnerable children can make a tremendous positive or negative impact on their experience and reaction to the care we provide. Children may be scared by either a poor choice of words ( we'll give this a shot ) or language they either do not understand or misunderstand. Making unrealistic promises ( this won't hurt ) or invalidat- ing feelings ( that doesn't really hurt ) only serves to undermine your relationship with the patient. Painful treatments should never be used as threats or punishments. Take care to keep needles or needle/syringe images out of view when possible. When possible, keep the patient close to eye level and let them sit up whenever feasible. Last, children are usually very concerned about losing blood. When they see their own blood, they may benefit from reassurance that the amount of blood loss is not harmful to them.

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD VOL. 11, NO. 1 35

Keys to an optimal rapport with your patient include honesty, clarity, and empowerment. Give them choices wherever possible. The key is recog- nizing which patient may benefit from detailed information and which patient copes better with distraction. While many children are extremely frightened of needles, some have worse anxiety when they cannot see what is happening to them. Distraction is a potentially powerful intervention and generally easier to implement at younger ages. Hypnosis, an advanced form of distraction, has a long track record of effective pain control in many acute and chronic pain situations. There is considerable evidence in the literature that supports family presence in the medical setting. Researchers have found that with clear guidelines and support, patients and family mem- bers report greater preference for family presence even in critical situations. Clinicians in these studies report no increase in adverse outcomes when family members are present and experts in the field report a lower medicolegal risk when family members are present at end of life settings. The key to family presence is providing skilled personnel such as clergy, nurses, or child life services to guide the family members about where they should be in a trauma room and under what circumstances they may be asked to leave. If your institution does not already have a policy describ- ing how to provide safe and effective family presence, there are multiple resources available to develop such a policy. 58-63 The concepts listed above do not require a medical license or sophisticated understanding of pharmacology. Rather, they require a basic under- standing of child development and a willingness and ability to pay attention to verbal and nonverbal cues of distress. When practiced and performed well they can make the difference between an optimal situation and one that is unmanageable.

Pharmacologic Interventions

In a sense, all analgesics are nerve blocks. Whether a pain signal is interrupted by a local or generalized anesthetic, systemic opioid, or effective distraction, each intervention works by attenuating the pain signal at some level. The keys to safe and effective use of medications include an understand- ing of the characteristics of the medications and a willingness to carefully titrate to effect. This section is not intended to provide an exhaustive list of available treatments. Attention will focus on general concepts with added detail about select and commonly available medications. A more

complete review of both pharmacologic and com- plementary approaches to analgesia is found in the references cited. 64-66

Acute Pain

The immediate goal of acute pain management is to get pain under control and then maintain that control. Even when the former is achieved, we often end up chasing the pain when we neglect to reassess and treat until the patient is again in severe distress. This results in both ineffective analgesia and more medication admin- istered. A secondary goal in acute pain manage- ment is the prevention of chronic pain. Through the careful titration of medication and attention to nonpainful stressors that worsen painful experi- ences, clinicians can provide safe and effective pain control in most patients. Opioids are usually the central therapy for managing severe acute pain. There is considerable variability of opioid responsiveness in some patients, and they may require significantly higher dosing. Such patients may either have differences in opioid receptors (often a familial pattern) or a higher tolerance due to chronic exposure to opioids. Of the numerous potential side effects of opioids, the most common are gastrointestinal dysmotility (nau- sea, pain, and constipation), sedation, and tolerance/ dependence. Proactive treatment of constipation is strongly recommended for patients receiving regular doses of opioids. Morphine, the gold standardanalgesic, has a relatively slow onset of action and a half-life of 2 to 3 hours. It is typically dosed as 0.05 to 0.1 mg/kg for the opioid-naïve patient in severe pain. Subsequent dosing of 0.02 to 0.05 mg/kg should take place every 10 minutes to desired level of analgesia. Although morphine is perhaps the most familiar opioid, it is sometimes not the ideal medication for trauma patients. Disadvantages include a slower onset, higher incidence of allergic reactions due to histamine release, more venodilation and risk of hypotension, and greater effects on gastrointestinal motility than other commonly used opioids. For the acutely injured patient whose initial evaluation is still in progress, fentanyl offers a number of advantages. Fentanyl is metabolized in the liver to inactive compounds; however, this is not significantly altered in liver disease. Onset is within 5 minutes and therapeutic levels are achieved for 20 to 60 minutes. Typically, the opioid-naïve patient in severe pain is safely and effectively treated with an initial dose of 2 to 3 μ g/kg of fentanyl. A continuous infusion can sustain therapeutic levels and allow

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careful titration. In addition, the literature shows growing interest in intranasal administration of fentanyl. This offers the obvious advantage of analgesia without intravenous access. Some studies suggest that a dose of 1.7 μ g/kg of intranasal fentanyl is equivalent to 0.1 mg/kg of morphine. 67 In this author's experience, a higher dose of fentanyl (2-3 μ g/kg) is required for mild-moderate pain. Oral transmucosal fentanyl is another option; however, effective doses by this route are associated with high rates (25%-50%) of nausea and vomiting. 68 Finally, hydromorphone offers several potential advantages to morphine and fentanyl including fewer allergic reactions, longer duration of action, and somewhat less tolerance when used for prolonged periods. Opioids are ideally dosed to maintain a steady state serum concentration and avoid peaks and troughs. Once pain control is achieved, it is important to anticipate the need for boluses of analgesia. Even small movements, turning the patient or inadvertently bumping a chest tube or endotracheal tube can cause significant exacerba- tions of pain. The patient with a femur fracture may appear to have good pain control when lying motionless but quickly loses that control when moved. Before moving the patient for x-rays or other reasons, consider a small (1-2 μ g/kg of fentanyl) bolus administered several minutes in advance of anticipated movement. If the patient seems excessively sedated fentanyl also has the advantage of a relatively short half-life. If opioid reversal is necessary in a stable but excessively sedated patient physicians should begin cautiously with small doses of naloxone (0.001 mg/kg per dose) to avoid excessive blockade of opioid and resulting severe pain. Although not commonly used in the ED setting, some pediatric EDs are using patient-controlled analgesia (PCA) for select patients (eg, sickle cell pain crisis) with good results. In general, PCA requires a patient with at least a 5-year-old developmental level. Although not all patients prefer this approach, many patients achieve greater control with lower doses of opioid when they have immediate control of their analgesia with a PCA. Typically, a basal infusion of opioid is provided with a limited number of PCA doses programmed into the PCA pump. Nonsteroidal antiinflammatory medications such as ibuprofen and ketorolac are potentially useful treatments either alone for mild pain or as adjuncts for moderate pain. Efficacy studies comparing ketorolac to morphine and acetaminophen have yielded mixed results. 69,70 Given the risk of de- creased platelet function and gastritis, the role for

regular use of nonsteroidal antiinflammatory med- ications in the acutely injured patient is therefore limited to situations where the risk for surgery is low and pain levels are not severe. Finally, nerve blockade at the spinal cord can provide effective analgesia with a fraction of the dose required for systemic treatment. Long-term use of epidural analgesia is possible and can offer appropriate candidates unique benefits. Although commonly used for labor pain, cesarean delivery, and thoracic and abdominal surgery in adults, many pediatric institutions do not yet routinely use this approach as it requires close observation from those trained in this procedure.

Sedation of the Trauma Patient

Sedation of the pediatric trauma patient poses unique challenges due to the risk of shock from blood loss and CNS injury due to altered cerebral perfusion pressures secondary to intracranial swell- ing. In addition, these patients often require analgesia for pain. Although multiple studies have shown that preprocedural fasting times do not correlate with aspiration, the clinician should consider the risks of nausea and vomiting in each situation. 71 The ideal sedatives for the necessary procedure in an acutely injured pediatric patient include the following properties: analgesia, minimal alteration in systemic and intracranial perfusion pressures, and short acting or reversible. No single agent offers the ideal combination of benefits for all situations; therefore, clinicians must rely on differ- ent options often with a combination of agents. Expertise in a handful of modalities is a better investment than marginal familiarity with a broad array of treatments. Before starting sedation, one should verify that equipment, medications, and personnel are in place to respond effectively to a sudden decrease in ventilation or oxygenation, emesis, hypotension, or seizure. Have an airway technician immediately available if your intention is to provide moderate to deep sedation. Recall that in light sedation (previ- ously conscious sedation), the patient responds appropriately to physical and verbal stimuli. In deep sedation, the patient is not easily aroused, may have partial or complete loss of protective reflexes, and loses the ability to respond purposefully to physical or verbal stimuli. Last, anticipate when you might stop a procedure. Take for example a child who appears deeply sedated when untouched but screams during a painful orthopedic procedure. The orthopedist is focused on completing the procedure. The physician in charge of sedation should decide

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD VOL. 11, NO. 1 37

whether it is reasonable to attempt or complete the procedure or defer to another setting such as the operating room with general anesthesia. The following strategy may be helpful in choosing optimal sedation medications for a given scenario or procedure. These are general recommendations, and each case requires an individual assessment by a physician trained and experienced in sedating children. First, determine if the analgesia require- ment will be low (eg, laceration repair) or high (eg, reducing a fracture). Next, determine if the proce- dure is likely to be less than or greater than 5 minutes. The key is to provide effective sedation and analgesia with the least amount of medication. In all cases, local or regional anesthetic is recommended where possible to limit the dose and duration of systemic medications. Last, strongly consider an amnestic agent (eg, benzodiazepine) as an adjunct for frightening situations/procedures. Do not pro- ceed with a painful procedure until assured that the patient's sedation and analgesia is adequate. For lower analgesia requirements, fentanyl or nitrous oxide is recomme nded. Advantages of nitrous oxide include its rapid onset and recovery time and excellent anxiolysis; 72 fentanyl offers superior analgesia. Nitrous oxide requires specific apparatus including a scavenging system and famil- iarity with administration. Contraindications against sedation with nitrous oxide include first trimester pregnancy, pneumothorax, chronic respi- ratory disease, bowel obstruction, CNS injury or depression, and shock. 73 For more painful procedures, it is sometimes challenging to find a safe therapeutic window with fentanyl. In these cases, ketamine is often a good alternative as it can provide effective analgesia and sedation without loss of spontaneous respirations. 74

Ketamine tends to increase secretions and has a positive chronotropic and inotropic effect that can result in an increase in systemic pressures. Keta- mine administration is associated with increased intracranial pressure; however, this effect is atten- uated with benzodiazepine administration or hy- perventilation. Interestingly, one study of patients with traumatic brain injury found a decrease in intracranial pressure in patients given ketamine and propofol. 75 In addition, ketamine often causes emesis and dysphoria upon waking ( emergence reaction ). The former is associated with higher dosing and the latter with older children and adults. 11 Therefore, it is prudent to premedicate with atropine if increased secretions pose a prob- lem, consider an antiemetic such as ondansetron and warn the family of the possibility of an emergence reaction (estimated to occur in 50% of older children and adults). When a procedure requires more than 5 minutes, propofol is a useful agent. 76 Propofol can provide deep sedation without loss of spontaneous respirations and wears off within minutes of discontinuation. Side effects include negative inotropy, so special attention should be paid to the blood pressure in patients receiving fentanyl and propofol. Propofol is typically bolused with a starting dose of 1 to 3 mg/kg and then maintained with an infusion at 5 mg/kg per hour titrated to effect. Contraindications to propofol include soy or egg allergy. Alternatives to propofol include midazolam, etomidate, or methohexital ( Table 2 ).

Prolonged Acute Pain

Managing prolonged or chronic pain is quite different than acute pain and generally not the

TABLE 2. Treatment options for procedural sedation of the trauma patient. a

Analgesia Need

Duration

Recommendation

Alternatives

Mild-moderate

Short (b 5 min)

Fentanyl (IV, IN)

Nitrous oxide (when anxiety N pain)

Mild-moderate (eg, long laceration repair)

Long (N 5 min)

Fentanyl (IV, IN) + propofol

Fentanyl infusion; Fentanyl + midazolam, etomidate, OR methohexital

Moderate-severe

Short (b 5 min)

Ketamine

Moderate-severe

Long (N 5 min)

Ketamine + propofol

Ketamine infusion; ketamine + midazolam, etomidate, OR methohexital

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responsibility of those in the emergency or acute care setting. As a result, acute care providers are generally less familiar with approaches to chronic pain. Nevertheless, the acute care provider will care for patients having prolonged or chronic pain and will need an understanding of these issues. Usually, patients transition from intravenous to oral opioids within days after injury or surgery. Oral opioids are sometimes necessary for 1 to 2 addi- tional weeks. When patients have difficulty weaning from opioids one should consider the possible causes and alternative treatments. Opioid tolerance typically develops within a week of continuous use of the same opioid. Patients will exhibit a decreasing effect of similar doses of the medication. Although increased dosing can address this temporarily, it is usually more effective (ie, better analgesia with less medication) to switch to another opioid. Patients with increasing needs for boluses of analgesics (breakthrough pain) should be reassessed for both the causes of the pain and effectiveness of the pain plan. Although attention to the possibility of evolving organ damage is the priority, there are other common causes of increased opioid use in this setting. Sleep deprivation is often an overlooked source of poorly controlled pain. 77 Anxiety may build with repetitive painful procedures, greater awareness of injuries, and a sense of lack of control over the situation. Assuming more aggressive analgesia is not contra- indicated one may consider changing the opioid. Frequent need for a short-acting opioid should prompt a consideration to add a long-acting opioid such as methadone or long-acting formulations of morphine, oxycodone, o r hydromorphone. The objective is to find an effective dose and dosing schedule that minimizes the peaks and troughs of medication level and pain control. Any changes in treatment strategy for patients with chronic pain must involve the advice and ongoing care of a knowledgeable physician. Nonopioid adjuncts may have an opioid-sparing effect and control the development of chronic pain. Unfortunately, pediatric trials for most of these adjuncts are lacking, particularly for pediatric trauma patients. A wide array of anticonvulsant medications have demonstrated effectiveness for various chronic pain syndromes. Gabapentin's possible effectiveness for phantom limb pain and spinal cord injury pain in addition to its relatively benign side effect profile make it a reasonable consideration for some trauma patients. 78 Canna- boid therapy may offer some analgesia in addition to effectiveness as an anxiolytic and antiemetic. 79 Ketamine is a potent NMDA receptor antagonist

that has demonstrated effectiveness in suppressing postsurgical central sensitization and secondary

hyperalgesia after burns. It has also been used effectively in the treatment of postamputation stump pain and complex regional pain syndrome. 80 Tricyclic antidepressants such as amitriptyline have

a long track record of effectiveness in a variety of chronic pain syndromes. Amitriptyline's sedative effects may also help treat insomnia. More recent serotonin selective reuptake inhibitors have also shown some effectiveness. 81

SUMMARY

Analgesia for the pediatric trauma patient remains

a challenging and important area of research and

clinical care. The relative infrequency of cases and multidimensional nature of injuries makes clinical research daunting. Undertreatment of these patients continues due to a variety of influences including excessive fears about adverse effects of analgesics, a lack of attention to pain, and underappreciation of the harmful effects of poorly controlled pain. Medical education and training still underserves the issue of pain in the context of patient care. Numerous national and institutional guidelines and require- ments have modest impact as the standards of care for analgesia are usually locally based. Fortunately, the tools to improve care are within our grasp. Common pharmacologic and nonpharmacologic interventions are safe and effective if used in a judicious manner. Analgesia protocols for prehospital and hospital-based care can improve the percentages of patients treated; ultimately, the attitudes and understanding of providers regarding analgesia must evolve to

achieve significant improvements in pain control. The emergency physician's responsibility in caring for a patient includes effective pain relief during their care and until the patient is transferred to a subsequent physician. Once we recognize that the potential harm in primum non nocere lies as much in undertreatment as in overtreatment of pain, children having injury will receive more

effective analgesia.

having injury will receive more effective analgesia. REFERENCES 1. Bielefeldt K, Gebhart GF. Visceral pain:

REFERENCES

1. Bielefeldt K, Gebhart GF. Visceral pain: basic mechanisms. In: McMahon SB, Koltzenburg M, editors. Wall and Melz- back's textbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 721-36. 2. Schaible H. Basic mechanisms of deep somatic pain. In:

McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th ed. Philadelphia (PA): Elsevier; 2006. p. 621-31.

ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD VOL. 11, NO. 1 39

3.

Pasero C, Portenoy RK, McCaffery M. Opioid analgesics. In:

24. Jones JS, Johnson K, McNinch M. Age as a risk factor for

14:157-60.

McCaffery M, Pasero C, editors. Pain clinical manual. 2nd ed. St Louis (MO): Mosby; 1990. p. 271-2.

inadequate emergency department. Am J Emerg Med 1996;

4.

Hedderich R, Ness TJ. Analgesia for trauma and burns. Crit Care Clin 1999;15:167-84.

25. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA 1993;

5.

Anand KJS, Phil D, Hickey P. Halothane-morphine compared

269:1537-9.

with high dose sufentanil for anesthesia and post operative analgesia in neonatal cardiac surgery. N Engl J Med 1992;326:

26. Todd KH, Deaton C, D'Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med 2000;35:11-6.

1-9.

27. Michael GE, Sporer KA, Youngblood GM. Women are less

28. Friedland LR, Pancioli AM, Duncan KM. Pediatric emergency

6.

Saxe G, Stoddard F, Courtney D, et al. Relationship between

Beggs S, Fitzgerald M. Development of peripheral and spinal

Elsevier; 2007. p. 11-24.

likely than men to receive prehospital analgesia for isolated

7.

acute morphine and the course of PTSD in children with burns. J Am Acad Adolesc Psychiatr 2001;40:915-21.

extremity injuries. Am J Emerg Med 2007;25:901-6.

department analgesic practice. Pediatr Emerg Care 1997;13:

nociceptive systems. In: Anand KJS, Stevens BJ, McGrath PJ,

103-6.

editors. Pain in neonates and infants. 3rd ed. New York (NY):

29. O'Donnell J, Ferguson LP, Beattie TF. Use of analgesia in a paediatric accident and emergency department following

8.

Schechter NL, Zeltzer LK. Pediatric pain: new directions from

20:209-10.

limb trauma. Eur J Emerg Med 2002;9:5-8.

a developmental perspective. J Develop Behav Pediatr 1999;

30. Singer AJ, Thode HC. National analgesia prescribing patterns in emergency department patients with burns. J Burn Care

9.

Anand KJS, Al-Chaer ED, Bhutta AT, Hall RW. Development

Rehab 2002;23:361-5.

of suprapinal pain processing. In: Anand KJS, Stevens BJ, McGrath PJ, editors. Pain in neonates and infants. 3rd ed. New York (NY): Elsevier; 2007. p. 25-44.

31. Neighbor MN, Honner S, Kohn MA. Factors affecting emergency department opioid administration to severely injured patients. Acad Emerg Med 2004;11:1290-6.

10.

Woolf CJ, Salter MW. Plasticity and pain: role of the dorsal horn. In: McMahon SB, Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th ed. Philadelphia (PA):

32. White LJ, Cooper JD, Chambers RM, Gradisek RE. Prehos- pital use of analgesia for suspected extremity fractures. Prehosp Emerg Care 2000;4:205-8.

Elsevier; 2006. p. 91-105.

33. McEachin CC, McDermott JT, Swor R. Few emergency

11.

Kohrs R, Duriex M. Ketamine: teaching an old dog new tricks. Anesth Anal 1998;87:1186-93.

medical services patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care 2002;6:

12.

Fitzgerald M, de Lima J. Hyperalgesia and allodynia in

406-10.

infants. In: Finley GA, McGrath PJ, editors. Acute and procedural pain in infants and children. Seattle (WA): IASP Press. 2001. p. 1-12.

34. Curtis KM, Henriques HF, Fanciullo G, et al. A fentanyl based pain management protocol provides early analgesia for adult trauma patients. J Trauma Inj Infect Crit Care 2007;63:819-26.

13.

Anand KJS, Runeson B, Jacobson B, et al. Gastric suction at birth associated with long term risk for functional intestinal

Grunau RE, Tu MT. Long-term consequences of pain in

Elsevier; 2007. p. 45-55.

35. Fullerton-Gleason L, Crandall C, Sklar DP. Prehospital administration of morphine for isolated extremity injuries:

14.

disorders in later life. J Pediatr 2004;144:449-54.

a change in protocol reduces time to medication. Prehosp Emerg Care 2002;6:411-6.

human neonates. In: Anand KJS, Stevens BJ, McGrath PJ, editors. Pain in neonates and infants. 3th ed. New York (NY):

36. DeVellis P, Thomas SH, Wedel SK, et al. Prehospital fentanyl analgesia in air-transported pediatric trauma patients. Pediatr Emerg Care 1998;14:321-3.

15.

Meyer RA, Ringkamp M, Campbell JN, Raja SN. Peripheral mechanisms of cutaneous nociception. In: McMahon SB,

37. Thomas SH, Rago O, Harrison T, et al. Fentanyl trauma analgesia use in medical scene transports. J Emerg Med 2005;

Koltzenburg M, editors. Wall and Melzback's textbook of pain. 5th. ed. Philadelphia (PA): Elsevier; 2006. p. 3-34.

29:179-87.

38. Frakes MA, Lord WR, Kociszewski C, et al. Efficacy of

16.

Schechter NL. The under-treatment of pain in children: an overview. Pediatr Clin North Am 1989;36:781-93.

fentanyl analgesia for trauma in critical care transport. Am J Emerg Med 2006;24:286-9.

17.

Selbst SM. Analgesic use in the emergency department. Ann Emerg Med 1990;19:1010-3.

39. Swor R, McEachin CM, Seguin D, et al. Prehospital pain management in children suffering traumatic injury. Prehosp

18.

Petrack EM, Christopher NC, Kriwinsky J. Pain management

Emerg Care 2005;9:40-3.

in the emergency department: patterns of utilization. Pediatrics 1997;99:711-4.

40. Zohar Z, Eitan A, Halperin P, et al. Pain relief in major trauma patients: an Israeli perspective. J Trauma 2001;51:767-72.

19.

Friedland LR, Kulick RM. Emergency department analgesic use in pediatric trauma victims with fractures. Ann Emerg

Broome ME, Richtsmeier A, Maikler V, Alexander M.

41. Silen W. Cope's early diagnosis of the acute abdomen. 19th ed. New York (NY): Oxford University Press; 1996.

20.

Med 1994;23:203-7.

42. Attard AR, Corlett MJ, Kidner NJ, et al. Safety of early pain relief for acute abdominal pain. BMJ 1992;305:554-6.

Pediatric pain practices: a national survey of health profes- sionals. J Pain Symptom Manage 1996;11:312-20.

43. Vermulean B, Morabia A, Unger PF, et al. Acute appendicitis:

influence of early pain relief on the accuracy of clinical and

21.

Cummings EA, Reid GJ, Finley GA, et al. Prevalence and source of pain in pediatric inpatients. Pain 1996;68:25-31.

US findings in the decision to operatea randomized trial. Radiology 1999;210:639-43.

22.

Cimpello L, Khine H, Avner JR. Practice patterns of pediatric vs general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care 2004;20:

44. LoVecchio F, Oster N, Sturmann K, et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997;15:775-9.

228-32.

45. Kim MK, Strait RT, Sato TT, et al. A Randomized clinical trial

23.

Quinn M, Carraccio C, Sacchetti A. Pain, punctures, and pediatricians. Pediatr Emerg Care 1993;9:12-4.

of analgesia in children with acute abdominal pain. Acad Emerg Med 2002;9:281-7.

40

VOL. 11, NO. 1 ANALGESIA FOR THE PEDIATRIC TRAUMA PATIENT / GREENWALD

46. Buduhan G, McRitchie DI. Missed injuries in patients with multiple trauma. J Trauma 2000;49:600-5.

47. Lazarus HM, Fox J, Evans RS, et al. Adverse drug reactions in trauma patients. J Trauma 2003;54:337-43.

48. Kanowitz A, Dunn TM, Kanowitz EM, et al. Safety and effectiveness of fentanyl administration for prehospital pain management. Prehosp Emerg Care 2006;10:1-7.

49. Devellis P, Thomas SH, Wedel SK, et al. Prehospital analgesia in air-transported pediatric trauma patients. Pediatr Emerg Care 1998;14:321-3.

50. Whipple JK, Lewis KS, Quebbeman EJ, et al. Analysis of pain management in critically ill patients. Pharmocotherapy

1995;15:592-9.

51. Silka PA, Roth MM, Moreno G, et al. Pain scores improve analgesic administration patterns for trauma patients in the emergency department. Acad Emerg Med 2004;11:

264-70.

52. Kaplan CP, Sison C, Platt SL. Does a pain scale improve pain assessment in the pediatric emergency department. Pediatr Emerg Care 2008;24:605-8.

53. Tanabe P, Buschmann M. Emergency nurses' knowledge of pain management principles. J Emerg Nurs 2000;26:299-305.

54. Hennes H, Kim MK, Pirrallo RG. Pre-hospital pain manage- ment: a comparison of providers' perceptions and practices. Prehosp Emerg Care 2005;9:32-9.

55. American College of Surgeons. Advanced trauma life support student manual. Chicago (Ill): American College of Surgeons

2004. p. 27.

56. American College of Surgeons. Advanced trauma life support student manual. Chicago (Ill): American College of Surgeons

2008. p. 169, 200.

57. Emergency Nurses Association. Course in advanced trauma nursing: a conceptual appro ach. Park Ridge (Ill): The Emergency Nurses Association; 1995. p. 253-78.

58. Rominson SM, Mackenzie-Ross S, Campbel-Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. The Lancet 1998;352:614-7.

59. Sacchetti A, Lichenstein R, Carraccio CA, et al. Family member presence during pediatric emergency department procedures. Pediatr Emerg Care 1996;12:268-71.

60. Meers T, Eichorn D, Guzzetta C. Do families want to be present during CPR? A retrospective study. J Emerg Nurs

1998;24:400-5.

61. Boie E, Moore G, Brummett C, et al. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Ann Emerg Med 1999;34:70-4.

62. Powers K, Rubenstein J. Family presence during invasive procedures in the pediatric intensive care unit: a prospective study. Arch Pediatr Adolesc Med 1999;153:955-8.

63. Sacchetti A, Paston C, Carraccio C. Family members do not disrupt care when present during invasive procedures. Acad Emerg Med 2005;12:477-9.

64. Kennedy RM, Luhman J. The ouchless emergency depart- ment.