Review
Prehospital pain management of injured children: a systematic review of current evidence

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Abstract

Objectives

Injury is a common cause of acute pain in children. The objective of this study was to analyze the available evidence in prehospital pain management of injured children.

Methods

The Patient/Population, Intervention, Comparator, and Outcome question was as follows: “In pediatric patients requiring prehospital analgesia for traumatic injuries, what is the level of evidence (LOE) available for the safety and efficacy of pharmacologic interventions?” The electronic databases MEDLINE/PUBMED, EMBASE, and Google Scholar were searched to identify all the relevant articles published in electronic journals, books, and scientific Web sites over the last 20 years. Studies were included if they reported on prehospital use of analgesics in injured children. Reviews, editorials, and surveys were excluded.

Results

Nineteen studies met the inclusion criteria. Thirteen were pediatric studies and 6 were studies of both adults and children. Nine were nonrandomized studies with concurrent controls (LOE-2), and 10 were retrospective case series and chart reviews (LOE-4). A measurable effect of analgesia was consistently found when analgesics were provided en route to the hospital; however, most studies reported a relatively low rate of analgesic use.

Conclusions

Only a few studies examined the efficacy of pediatric prehospital analgesia. Fentanyl at a dose of 1 to 3 μg/mg seems to have an accepted efficacy. The current level of evidence is insufficient to assess the safety profile of analgesics. The findings of this study suggest that the analgesic treatment of injured children in the prehospital setting is suboptimal.

Introduction

Relief of acute pain in children is increasingly recognized as an important and integral part of emergency care [1]. In prehospital settings, injuries are the most common cause of pain in children and should be treated appropriately [2]. Acute traumatic pain, when inadequately treated, has been found to have both immediate and long-lasting effects [3]. Emergency medical services (EMS) personnel report that the major challenges preventing or delaying the relief of acute pain during initial treatment include an inability to assess pain and fasting times, and a limited choice of agents and delivery routes. Variability in provider education and different beliefs have also been mentioned as barriers to providing this treatment, and they are potential areas of intervention [4], [5]. These challenges, although present in the emergency department (ED), are even more pronounced in the prehospital setting and more marked in pediatric patients than in adults [6].

In recent years, a few initiatives sought to develop treatment guidelines for acute pediatric pain [1], [7], [8]. All mentioned a lack of high-level evidence and a need for further research in prehospital pain management [9]. Current guidelines and reviews of prehospital pediatric care refer to evidence found in adult studies or from studies performed in EDs. This extrapolation may be necessary, yet it carries inherent limitations, due to significant differences in setting and provider profiles.

The purpose of this review was to analyze the current level of evidence (LOE) in prehospital pain management of injured children, focusing on the safety and efficacy of prehospital analgesia.

Section snippets

Methods

This review was conducted in accordance with the International Liaison Committee on Resuscitation 2010 evidence evaluation process [10]. Review of the search strategy and findings was conducted by the three authors of the article.

Results

The search yielded 2404 articles. Nineteen studies met the inclusion criteria (Table 2). Of these, 13 were dedicated pediatric studies and 6 were studies of both adults and children. Of the 19 studies, 9 were LOE-2 (nonrandomized, concurrent controls) and 10 were LOE-4 (retrospective case series and chart reviews). (Figure)

Efficacy

The current evidence (LOE-2) seems to show that fentanyl in a dose of 1 to 3 μg/kg has an accepted efficacy for the treatment of injured children in the prehospital setting. A potential for fentanyl using the nasal route has been recently highlighted in a Cochrane review [29]. Comparing the efficacy of other medications cannot be based on the current evidence; however, a measurable effect of analgesia has been consistently shown when analgesics were provided en route to the hospital (LOE-2 and

Conclusions

Only a few studies examined the efficacy of pediatric prehospital analgesia. Pediatric prehospital analgesia seems effective and has a measurable effect. Fentanyl in a dose of 1 to 3 μg/mg seems to have an accepted efficacy. The current LOE is insufficient to assess the safety profile of analgesics. The findings of this study suggest that the analgesic treatment of injured children in the prehospital setting is suboptimal.

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    Disclosures: There was no specific funding source or dedicated financial support for this study. No author has any conflict of interest to declare. No honorarium, grant, or other form of payment was given to anyone to produce the article. The authors have not published or submitted any related papers from the same study. The corresponding author (NS) had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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