Journal Watch: Pain Management and ED Care in Kids

Reviewed This Month

Impact of Prehospital Pain Management on Emergency Department Management of Injured Children

Authors: Harris MI, Adelgais KM, Linakis SW, et al.

Published in: Prehosp Emerg Care, 2021 Nov 4; 1–12 

Caring for children in the prehospital environment can be challenging. We don’t see them as often as older patients, which is fantastic, since no one wants to see children hurt or sick. However, less familiarity with caring for pediatric patients can make it difficult for EMS professionals to feel comfortable and confident doing it. This can lead to thinking we should just scoop little ones up and get them to an ED, but what if the care EMS provides to pediatric patients impacts the care they receive in the ED? If improvements in prehospital care led to overall improvements throughout the continuum of care, we might rethink how we care for our most vulnerable patients. 

The study we review in this month’s Journal Watch sought to determine the impact of prehospital pain interventions on initial ED pain-scale scores and timing and dosing of ED analgesia for injured pediatric patients transported by EMS. 

This study was a planned secondary analysis of a prospective multicenter cohort study of children with actual or suspected injuries. The 11 EDs participating in this study were part of the Pediatric Emergency Care Applied Research Network (PECARN). PECARN is the first federally funded multi-institutional network for research in pediatric emergency medicine in the United States. The goal of this network is to conduct meaningful and rigorous multi-institutional research into the prevention and management of acute illnesses and injuries in children and youth across the continuum of emergency medicine healthcare. 

Study Parameters

Patients included in the study were 1 month to 17 years old and had injury-related chief complaints. The study took place from July 2019 to April 2020. Patients in traumatic arrest, with known hypersensitivity to opioids, or known to be pregnant were excluded. Eligible patients were prospectively enrolled by research coordinators who then collected data from the EMS providers seven days a week, including whether the patient was provided pharmacologic or nonpharmacologic pain-management interventions. 

When this information could not be collected directly from the EMS provider, EMS and ED records were reviewed, and this information was abstracted where available. EMS and ED data were linked using patient name, date of birth, chief complaint, and encounter date and time. In addition to pain-management interventions, data collection included patient demographics, ED pain scores, timing and dose of analgesic medications administered, patient disposition, and discharge diagnosis. Pain-severity scores were categorized as mild (0–3), moderate (4–6), or severe (7–10). All analgesic medications administered were converted to morphine equivalents. 

The primary study objective was to compare the difference in prehospital and ED pain scores between those patients who received opioid analgesia and/or nonpharmacologic prehospital pain management and those who did not receive any pain-management interventions. The authors also examined secondary outcome measures, including time to first administration of ED opioid analgesia and total morphine equivalents administered in the ED. Comparisons were made between the groups that received only nonpharmacologic EMS interventions and those that received a combination of both pharmacologic and nonpharmacologic interventions in the prehospital environment. 

Results

There were 474 patients included in the analysis. Fifty-nine percent were male, and the median age was 11.4 years. Only 77% of patients (whose chief complaint was injury-related!) had a documented pain-severity score. Prehospital pain interventions were performed on only 55% of these pediatric patients, and fewer than 1 in 5 (19%) received prehospital opioids. 

Among children with pain scores categorized as severe, only 36% received prehospital opioids. This decreased to only 8% among those with moderate and 1% among those with low pain-severity scores. Notably, those who received prehospital opioids (alone or in combination with nonpharmacologic pain management) showed a greater reduction in their pain severity upon ED arrival, with a reduction of 2.1 pain-score points among those who received opioids alone, 2.6 points among those who received opioids with nonpharmacologic pain management, and less than 1 point among those who received nonpharmacologic pain management only and those who received no pain management. 

Children who received opioid analgesia, either alone or in combination with prehospital nonpharmacologic interventions, were more likely to receive ED opioid analgesia as well as higher doses of opioid analgesia both in the first hour and throughout ED care (p<0.001). Further, children who received nonpharmacologic interventions alone in the prehospital environment received higher doses of opioids within the first hour of arrival at the ED compared to those who did not receive any pain management (p<0.05). 

Conclusion

As with all studies, this one has limitations. Unfortunately, the authors did not collect the type of opioid, route of administration, or dose delivered by EMS. This makes it impossible to evaluate the efficacy of specific opioids or how the choice of route or dose impacted ED care. The study also did not evaluate pain medications other than opioids, such as NSAIDs or ketamine. Finally, the type of nonpharmacologic intervention was not captured. 

Even with the limitations described above, though, this is an important study. Not only do these results suggest EMS can improve the care we provide to these patients before we transfer care, but this study also shows that care provided by EMS can influence how the patient is treated in the ED. This study also highlights that EMS may not be treating pain as much as it should. 

If EMS appropriately assesses and treats pain in children, we can reduce suffering while they are in our care and positively impact the care they are provided after we transfer them. I congratulate the authors on publishing this important study.   

Antonio R. Fernandez, PhD, NRP, FAHA, is a research scientist at ESO and serves on the board of advisors of the Prehospital Care Research Forum at UCLA.