Pain management assessment in children with limb fractures in an emergency service
Introduction: The tool most widely used for measuring the intensity of pain in children is the Faces Pain Score - Revised (FPS-R). Pain management depends on the level of care and the knowledge of the physician regarding dosing, indications and side effects of the medications available for use.
Objective: To assess pain management in patients 3-17 years of age with limb fractures using the FPS-R within the first 6 h.
Materials and methods: Observational cohort of patients 3-17 years of age presenting with limb fractures between October 2013 and January 2014. Patients with comorbidities associated with chronic pain were excluded. The tool was administered four times in accordance with the validated instructions - on admission, at first hour, at three hours and at six hours.
Results: Overall, 60 patients were assessed and 4 pharmacological regimens were identified: dipyrone alone (63.3%), combined therapy with dipyrone plus tramadol (10%), tramadol alone (8.3%), acetaminophen alone (6.6%).
The mean pain intensity reduction with the use of dipyrone was 1.7 points on the FPS-R within the first hour, with a mean reduction of 4 points by the end of the six hours of follow-up. With tramadol, pain reduction was 1.6 points and 4.6 points, respectively. The combined use of dipyrone plus tramadol did not result in significant pain reduction within the first hour.
Conclusion: Fracture immobilization is the mainstay for analgesia but it does not suffice as a form of pain management. Monotherapy with dipyrone or tramadol resulted in the best pain reduction, whereas the combined use of dipyrone plus tramadol was not better than the use of either medication alone.
2. Stinson JN, Kavanagh T, Yamada J. Systematic review of the psychometric properties, interpretability and feasibility of self-report pain intensity measures for use in clinical trials in children and adolescents. Pain. 2006;125:143-5.
3. Von Baeyer CL, Spagrud LJ. Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain. 2007;127:140-50.
4. Cohen LL, La Greca AM, Blount RL, Kazak AE, Holmbeck GN, Lemanek KL. Introduction to special issue: evidence-based assessment in pediatric psychology. J Pediatr Psychol. 2008;33:911-5.
5. Hicks CL, Baeyer V, Spafford PA, Korlaar IV, Goodenough B. The Faces Pain Scale Revised: toward a common metric in pediatric pain measurement. Pain. 2001;93:173-83.
6. Chambers CT, Craig KD. An intrusive impact of anchors in children's Faces Pain Scales. Pain. 1998;78:27-37.
7. Miró J, Huguet A. Evaluation of reliability, validity, and preference for a pediatric pain intensity scale: the Catalan version of the Faces Pain Scale-revised. Pain. 2004;111:59-64.
8. Perrott DA, Goodenough B, Champion GD. Children's ratings of the intensity and unpleasantness of post-operative pain using facial expression scales. Eur J Pain. 2004;8:119-27.
9. McGrath PA, Seifert CE, Speechley KN, Booth JC, Stitt L, Gibson MC. A new analogue scale for assessing children's pain: an initial validation study. Pain. 1996;64:435-43.
10. Rogovik AL, Rostami M, Hussain S, Goldman RD. Physician pain reminder as an intervention to enhance analgesia for extremity and clavicle injuries in pediatric emergency. J Pain. 2007;8:26-32.
11. Vitale MG, Choe JC, Hwang MW, Bauer RM, Hyman JE, Lee FY, Roye DP Jr. Use of ketorolac tromethamine in children undergoing scoliosis surgery: an analysis of complications. Spine J. 2003;3:55-62.
12. Consolidated list of products whose consumption and/or sale have been banned, withdrawn, severely restricted or not approved by governments. Twelfth issue. Pharmaceuticals. United nations 2005. (Seen on October 3, 2013 at URL: http://www.un.org/esa/coordination/CL12.pdf).
13. Stamer UM, Soehle M, Park TW, Fischer M, Stuber F. Anaphylactic reaction after intravenous dipyrone. Acute Pain. 2007;9:221-7.
14. Edwards JE, McQuay HJ. Dipyrone and agranulocytosis: what is the risk? Lancet. 2002;360:1438.
15. International Agranulocytosis, Aplastic Anemia Study. Risk of agranulocytosis and Aplasic anaemia. A first report of their relation to drug use with special reference to analgesics. JAMA. 1986;256:1749-57.
16. Hamerschlak N, Maluf E, Biasi Cavalcanti A, Avezum Júnior A, Eluf-Neto J, Passeto Falcão R, Lorand-Metze IG, et al. Incidence and risk factors for agranulocytosis in Latin American countries-the Latin Study: a multicenter study. Eur J Clin Pharmacol. 2008;64:921-9.
17. Machado-Alba JE, Urbano-Garzon SF, Gallo-Gomez YN, Zuluaica S, Henao Y, Parrado- Fajardo IY. Reacción de anafilaxia grave por dipirona sin antecedente de hipersensibilidad. Informe de caso. Rev Colomb Anestesiol. 2016. In press.
18. Drendel AL, Gorelick MH, Weisman SJ, Lyon R, Brousseau DC, Kim MK. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain. Ann Emerg Med. 2009;54:553-60.
19. Ortega HW, Vander H, Lin CW, Engels JA, Reid S. Does age affect analgesia provision at discharge among children with long bone fractures requiring emergency care? J Emerg Med. 2013;45:649-57.
20. Mader TJ, Ames A, Letourneau P. Pain management in paediatric trauma patients with long bone fracture. Injury. 2006;37:61-5.
Copyright (c) 2016 Sociedad Colombiana de Anestesiología y Reanimación. S.C.A.R.E
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.