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To compare the extent of tissue damage produced by conventional cold steel and coblation tonsillectomy.
Twenty patients underwent conventional and 18 underwent coblation tonsillectomy. The removed tonsils were histopathologically evaluated.
Analgesic use was lower in the coblation group during the early post-operative period. Histological investigation of tonsils removed by the conventional method showed intensive haemorrhage and hyperaemia in the tonsillar capsules, which was not seen in the coblation group. Furthermore, in the coblation group, there was less mast cell degranulation (p = 0.0081) and a smaller amount of skeletal muscle tissue (p = 0.0043) in the tonsillar capsules, indicating less tissue damage.
Compared to the cold steel technique, coblation tonsillectomy is superior in terms of less early post-operative pain and less damage to surrounding tissues. Significantly lower mast cell degranulation in coblation tonsillectomy may contribute to the reduction of post-operative pain.
With regionalized trauma care, medical transport times can be prolonged, requiring paramedics to manage patient care and symptoms. Our objective was to evaluate pain management during air transport of trauma patients.
We conducted a 12-month review of electronic paramedic records from a provincial critical care transport agency. Patients were included if they were ≥18 years old and underwent air transport to a trauma centre, and excluded if they were Glasgow Coma Scale score <14, intubated, or accompanied by a physician or nurse. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment via 11-point numerical rating scale, patterns of analgesia administration, and analgesia-related adverse events. Results were reported as mean ± standard deviation, [range], (percentage).
We included 372 patients: 47.0 years old; 262 males; 361 blunt injuries. Transport duration was 82.4 ± 46.3 minutes. In 232 (62.4%) patients who received analgesia, baseline numerical rating scale was 5.9 ± 2.5. Fentanyl was most commonly administered at 44.3 [25–60] mcg. Numerical rating scale after first analgesia dose decreased by 1.1 [-2–7]. Thereafter, 171 (73.7%) patients received 2.4 [1-18] additional doses. While 44 (23.4%) patients had no change in numerical rating scale after first analgesia dose, subsequent doses resulted in no change in numerical rating scale in over 65% of patients. There were 43 adverse events recorded, with nausea the most commonly reported (39.5%).
Initial and subsequent dose(s) of analgesic had minimal effect on pain as assessed via numerical rating scale, likely due in part to inadequate dosing. Future research is required to determine and address the barriers to proper analgesia.
The role of aromatherapy in supportive symptom management for pediatric patients receiving palliative care has been underexplored. This pilot study aimed to measure the impact of aromatherapy using validated child-reported nausea, pain, and mood scales 5 minutes and 60 minutes after aromatherapy exposure.
The 3 intervention arms included use of a symptom-specific aromatherapy sachet scent involving deep breathing. The parallel default control arm (for those children with medical exclusion criteria to aromatherapy) included use of a visual imagery picture envelope and deep breathing. Symptom burden was sequentially assessed at 5 and 60 minutes using the Baxter Retching Faces scale for nausea, the Wong-Baker FACES scale for pain, and the Children's Anxiety and Pain Scale (CAPS) for anxious mood. Ninety children or adolescents (mean age 9.4 years) at a free-standing children's hospital in the United States were included in each arm (total n = 180).
At 5 minutes, there was a mean improvement of 3/10 (standard deviation [SD] 2.21) on the nausea scale; 2.6/10 (SD 1.83) on the pain scale; and 1.6/5 (SD 0.93) on the mood scale for the aromatherapy cohort (p < 0.0001). Symptom burden remained improved at 60 minutes post-intervention (<0.0001). Visual imagery with deep breathing improved self-reports of symptoms but was not as consistently sustained at 60 minutes.
Significance of results
Aromatherapy represents an implementable supportive care intervention for pediatric patients receiving palliative care consults for symptom burden. The high number of children disqualified from the aromatherapy arm because of pulmonary or allergy indications warrants further attention to outcomes for additional breathing-based integrative modalities.
A common strategy for managing emergency department (ED) patients with low-risk abdominal pain is to discharge them home and arrange for next day outpatient ultrasound for further assessment. The objective was to determine the proportion of outpatient ultrasounds with findings requiring intervention within 14 days.
This was a retrospective chart review of non-pregnant patients ages 18 to 40 years, presenting to an academic ED (annual census 65,000) with an abdominal complaint for whom the emergency physician arranged an outpatient (next day) abdominal ultrasound.
Of the 299 included patients, 252 (84.3%) were female and mean (SD) age was 28.4 (6.0) years. Twenty-three (7.7%) patients had ultrasounds requiring intervention within 14 days of imaging. Of these, eight (34.8%) had appendicitis, five (21.7%) had cholecystitis, four (17.4%) had urological pathology, three (13.0%) had gynecological pathology, and three (13.0%) had gastrointestinal diagnoses. Of note, 14 (60.9%) patients requiring follow-up or intervention within 14 days had symptoms that improved or resolved at the time of the outpatient ultrasound. For the 277 (92.6%) patients not requiring intervention, 117 (42.2%) had improved, 89 (32.1%) were unchanged, 50 (18.1%) had resolved, and 5 (1.8%) had worsened symptoms at the time of the follow-up ultrasound. Of the non-intervention patients, 13 (4.7%) went on to have alternative imaging, including magnetic resonance imaging, computed tomography, and a sonohysterogram.
Next-day ultrasound imaging remains a good way of identifying patients with serious pathology not appreciated at the time of their ED visit.
It has taken more than 40 years for the fields of immunology and neuroscience to capture the potential impact of the mechanistic understanding of how an active immune signalling brain might function. These developments have grown an appreciation for the immunocompetent cells of the central nervous system and their key role in the health and disease of the brain and spinal cord. Moreover, the understanding of the bidirectional communication between the brain and the peripheral immune system has evolved to capture an understanding of how mood can alter immune function and vice versa. These concepts are rapidly evolving the field of psychiatry and medicine as a whole. However, the advances in human medicine have not been capitalised upon yet in animal husbandry practice. Of specific attention are the implications that these biological systems have for creating and maintaining heightened pain states. This review will outline the key concepts of brain–immune communication and the immediate opportunities targeting this biology can have for husbandry practices, with a specific focus on pain.
Pain and depression are common in the population and co-morbid with each other. Both are predictive of one another and are also associated with cognitive function; people who are in greater pain and more depressed respectively perform less well on tests of cognitive function. It has been argued that pain might cause deterioration in cognitive function, whereas better cognitive function earlier in life might be a protective factor against the emergence of disease. When looking at the dynamic relationship between these in chronic diseases, studying samples that already have advanced disease progression often confounds this relationship.
Using data from waves 1 to 3 of the English Longitudinal Study of Ageing (ELSA) (n = 516), we examined the interplay between pain, cognitive function and depression in a subsample of respondents reporting a diagnosis of arthritis at wave 2 of the ELSA using cross-lagged panel models.
The models showed that pain, cognitive function and depression at wave 1, prior to diagnosis, predict pain at wave 2, and that pain at wave 1 predicts depression at wave 2. Pain and depression at wave 2 predict cognitive function at wave 3.
The results indicate that better cognitive function might be protective against the emergence of pain prior to an arthritis diagnosis, but cognitive function is subsequently impaired by pain and depression. Furthermore, higher depression predicts lower cognitive function, but not vice versa. This is discussed in the context of the emerging importance of inflammation in depression.
Gambling disorder (GD) is a common, disabling condition that often is exacerbated by stressful life events. Under stress, the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis are activated. The question, therefore, arises as to whether an abnormal sympathetic response can be found in individuals with GD.
Adult individuals with GD and no current co-occurring mental disorders were enrolled. Participants completed impulsivity and gambling-related questionnaires and underwent cold pressor evaluation. GD participants were compared with controls on measures of heart rate, blood pressure, and pain.
Fifteen people with GD and 18 controls completed the study. Kaplan–Meier analysis indicated that the GD group withdrew their hand from the painful stimulus more rapidly than controls (Wilcoxon chi-square = 3.87, p = 0.049), suggestive of lesser pain tolerance. Subjective pain ratings and cardiovascular measurements did not significantly differ between groups.
Individuals with GD manifested a relative intolerance to pain on the cold pressor paradigm, even though they physiologically did not seem to experience greater pain. Given the role of the opioid system in pain processing, it would be valuable in future work to examine whether cold pressor measures can predict response to treatments in GD, including with opioid antagonists.
The objectives were to evaluate the, usability, feasibility of use, satisfaction, and safety of the Syqe Inhaler Exo (Syqe Inhaler), a metered dose, Pharmacokinetics-validated, cannabis inhaler device in a cohort of hospitalized patients that were using medical cannabis under license as a part of their ongoing medical treatment.
Before and after inhaling from the Syqe Inhaler, participants were asked to fill a questionnaire regarding pain reduction on a visual analog scale from 0 to 10 and, if relevant, reduction in chemotherapy-induced nausea and vomiting and/or spasticity. A patient satisfaction questionnaire and a usability questionnaire were filled in following the last use. Prescribed treatment included 4 daily doses of 500 μg tetrahydrocannabinol each delivered from 16 mg cannabis flos per inhalation plus up to an additional four SOS (distress code for more doses of cannabis) doses.
Daily cannabis dose consumed during hospitalization with the Syqe Inhaler was 51 mg (20–96) versus 1,000 mg (660-3,300) consumed prehospitalization. Patients were easily trained and continued to use Syqe Inhaler for the duration of their hospitalization (5 [3–7] days). Pain intensity 30–60 minutes following inhalations was reported to be significantly lower than preinhalation 4 [1–5] versus 7 [2–9]). Participants ranked their satisfaction with Syqe Inhaler as 6 (5–7). Three participants reported mild cough, which resolved spontaneously.
Significance of results
Cannabis inhalation by combustion is not feasible for hospitalized patients. The use of Syqe Inhaler during hospitalization yielded high levels of patients and staff satisfaction with no complications.
We aimed to examine the association between pain, stiffness and fatigue in newly diagnosed polymyalgia rheumatica (PMR) patients using baseline data from a prospective cohort study. Fatigue is a known, but often ignored symptom of PMR. Newly diagnosed PMR patients were recruited from general practice and mailed a baseline questionnaire. This included a numerical rating scale for pain and stiffness severity, manikins identifying locations of pain and stiffness and the FACIT-Fatigue questionnaire. A total of 652 PMR patients responded (88.5%). The mean age of responders was 72.6 years (SD 9.0) and the majority were female (62.0%). Manikin data demonstrated that bilateral shoulder and hip pain and stiffness were common. The mean fatigue score (FACIT) was 33.9 (SD 12.4). Adjusted regression analysis demonstrated that a higher number of pain sites (23–44 sites) and higher pain and stiffness severity were associated with greater levels of fatigue. In newly diagnosed PMR patients, fatigue was associated with PMR symptom severity.
Introduction: Emergency Department (ED) opioid prescribing has been linked to long-term use and dependence. Small packets of opioid medications are sometimes prescribed at discharge, i.e. ‘To-Go’, in an attempt to treat pain but avoid unintended consequences. The extent of this practice and its associated risks are not fully understood. This study's objective was to describe the use of ‘To-Go’ opioids in a large urban center. Methods: Multicenter linked administrative databases were used to recruit an observational cohort. The referral population was comprised of all patients discharged from a Calgary ED in 2016 (four hospitals) with an arrival pain score greater than 0. We first described this population and then performed a multivariable analysis to assess for predictors of ‘To-Go’ opioids. ‘To-Go’ opioids were either Tylenol-Codeine or Tylenol-Oxycodone. Results: A total of 88,855 patients were recruited. The majority were female (57%) and the average age was 44.5 yrs. Abdominal pain was the most frequent complaint (22.1%) followed by extremity (18.3%) and cardiac pain (8.0%). Overall, 2,736 patients (3.1%) received an opioid ‘To-Go’ with significant variation in prescribing rates across hospitals (1.8-5% Chi2 p < 0.05). Logistic regression (covariates: age, sex, CTAS, pain score, type of pain, hospital, ED opioid, length of stay) revealed that receiving an opioid (IV or PO) prior to discharge was the strongest predictor of ‘To-Go’ opioid (OR 6.4 [5.9-7.0]). Hospital (OR 1.4 [1.3-1.4]) and male sex (OR 1.2 [1.1-1.3]) also emerged as predictors, whereas age over 65 decreased the odds of ‘To-Go’ opioid (OR 0.8 [0.6-0.9]). Hospital-specific ORs ranged from 1.3-2.7. Conclusion: In comparable patient populations some hospitals are more likely than others to provide a short course of opioids at discharge. This difference is not explained by patient demographics, pain profiles, or medications prior to discharge. The reasons for this variation are unclear but it underscores the need to determine the risks of ED opioid exposures and develop clear evidence-based prescribing guidelines.
Introduction: Acute migraine headaches are common causes of presentation to the emergency department (ED). There is great variability in the efficacy of the available parenteral agents to manage pain, though triptans are among the recommended treatments. The objective of this systematic review was to update a previous review examining the effectiveness of parenteral agents for the treatment of acute migraine in the ED or equivalent acute care setting; our review examined pain management in emergency settings and assessed the effectiveness of triptan agents. Methods: A comprehensive search of 10 electronic databases and grey literature was conducted to supplement the previous systematic review. Two independent reviewers completed study selection, quality assessment, and data extraction. Any discrepancies were resolved by third party adjudication. Pain scale scores were analyzed using standardized mean difference (SMD) with 95% confidence intervals (CIs) calculated using a random effects model; heterogeneity (I2) was reported. Results: Titles and abstracts of 5039 unique studies were reviewed, of which, 51 studies were included. Sixty-four studies from the original review were included, resulting in a total of 115 included studies. Pain was measured within the ED or equivalent acute care setting using a variety of pain scales, most commonly the 0-10 cm or 100 mm visual analog scale. Four studies compared pain scores between patients receiving sumatriptan vs. other agents, of which, patients receiving sumatriptan reported higher pain scale scores (SMD = 0.53; 95% CI: 0.04, 1.02; I2 = 80%). In particular, patients receiving sumatriptan reported higher pain scale scores than patients receiving metoclopramide (SMD = 0.68; 95% CI: 0.31, 1.04; n = 1) or ketorolac (SMD = 1.39; 95% CI: 0.56, 2.21; n = 1). Overall, studies comparing anti-inflammatory agents (i.e., ketorolac or dexketoprofen) to other agents reported improved pain scale scores among patients receiving anti-inflammatory agents (SMD = -0.38; 95% CI: -0.73, -0.03; I2 = 66%; n = 5). Conclusion: Limited evidence suggests that patients treated with metoclopramide or anti-inflammatory agents experience greater pain reduction compared to patients treated with sumatriptan. This review will conduct a network analysis of parenteral agents to examine the comparative effectiveness of parenteral agents to manage pain among patients with acute migraine. Further analysis will also consider the balance between efficacy and adverse events.
Introduction: Cannabis Hyperemesis Syndrome (CHS) is a new and poorly understood phenomenon with a subset of patients presenting to emergency departments (ED) for symptomatic control of their refractory nausea and vomiting. Curently, there is a lack of agreement and considerable practice variability on initial treatment modalities for CHS. The objective of this study was to describe the treatment modalities for patients presenting to ED with cannabis-related sequelae. Methods: This was a health records review of patients ≥18 years presenting to one of two tertiary care EDs (annual census: 150,000) with a discharge diagnosis including cannabis use with one of abdominal pain or nausea/vomiting using ICD-10 codes. Trained research personnel collected data from medical records including demographics, clinical history, results of investigations, and utilization of treatment options within the ED. Descriptive statistics are presented where appropriate. Results: From April 2014 to June 2016, 203 unique ED patients had a discharge diagnosis including cannabis use with abdominal pain or nausea/vomiting. Sixty-nine (33.4%) received any treatment during their visit with 28 (40.6%) receiving IV fluids, of which 24 (85.7%) received normal saline. Anti-emetics were used in 21 (30.4%) patients with ondansetron being the first-line agent in 11 (52.4%) patients followed by dimenhydrinate in 6 (28.6%) and haloperidol in 2 (9.5%) cases. Six patients required two doses of anti-emetics, favouring ondansetron in 3 cases followed by haloperidol, dimenhydrinate, and metoclopramide each used once. Thirteen (19%) patients required analgesia, with the first-line preference being non-opioid medications in 11 versus opioids in 2 cases. Seven patients required multiple modes of analgesia, favouring opioid medications in 4 patients. Twenty-eight (40.6%) patients required anxiolytics with lorazepam being used primarily in 16 (57.1%) patients followed by lorazepam/haloperidol in 5 (17.9%) cases. Conclusion: This ED-based study demonstrates variability of practice patterns for symptomatic treatment of cannabis related ED presentations. Despite knowledge of haloperidol being useful in patients with suspected CHS, physicians opted for ondansetron as first line anti-emetics. Future research should focus on studying various treatment modalities of patients with suspected CHS in the ED to optimize symptomatic treatment.
Introduction: The objective of the study was to evaluate the acute pain intensity evolution in ED discharged patients using Group-based trajectory modeling (GBTM). This method identified patient groups with similar profiles of change over time without assuming the existence of a particular pattern or number of groups. Methods: This was a prospective cohort study of ED patients aged ≥18 years with an acute pain condition (≤ 2 weeks) and discharged with an opioid prescription. Patients completed a 14-day diary assessing daily pain intensity level (0-10 numeric rating scale) and pain medication use. Results: Among the 372 included patients, six distinct post-ED pain intensity trajectories were identified: two started with severe levels of pain, one remained with severe pain intensity (12.6% of the sample) and the other ended with moderate pain intensity level (26.3%). Two other trajectories had severe initial pain, one decreased to mild pain (21.7%) and the other to no-pain (13.8%). Another trajectory had moderate initial pain which decreased to a mild level (15.9%) and the last one started with mild pain intensity and had no pain at the end of the 14-day (9.7%). The pain trajectory patterns were significantly associated with age, type of painful conditions, pain intensity at ED discharge, and with opioid consumption. Conclusion: Acute pain resolution following an ED visit seems to progress through six different trajectory patterns that are more informative than simple linear models and could be useful to adapt acute pain management in future research.
Background: Acute pain is a common presentation in the Emergency Department (ED) and inadequacy in its treatment can lengthen stay. Earlier analgesia use and discharge has been associated with positive patient experiences and improved pain management. Validated ‘fast-track pathways’ to aid physician decision making in analgesic administration is associated with decreased waiting times in renal colic diagnoses. Aim Statement: Our aim was to create an order set, for an approach to patients with acute pain, to reduce median time from point of triage to analgesia. We sought to reduce median time by 15 minutes, for ED patients with renal colic in the three months after implementation as compared to three months before. Measures & Design: We used a literature review and comparison to existing order sets at other EDs to design our draft. We focused our evaluation on patients with renal colic. We underwent multiple revisions based on stakeholder feedback and educated both physician and nursing teams about the order set. The utilization, however, was at physician discretion. We implemented the order set on March 30, 2017. After three months, an electronic retrospective chart review identified patients with a final renal colic diagnosis. For each patient, we captured triage time using electronic records and time to analgesia with the medication cart. Utilization of order sets was confirmed via manual chart audit. Evaluation/Results: A run chart showed worsening times after the intervention. Median time to analgesia in minutes, 3 months prior (n = 90) and post (n = 93) intervention, increased from 228 to 310 minutes, although the range was very large. Chart audits demonstrated a considerably low uptake of the order set with a small gradual increase from 0% to 20% over the 3-month period. Discussion/Impact: There was insufficient uptake of the Acute Pain order set preventing impact on time to analgesia. Changes in occupancy likely contributed to the worsening times. There was an increase in utilization over the 3-month period and could be due to increased awareness. This demonstrates that interventions require more than implementation to be effective. Difficulties in implementation were due to the document not being readily available. We have organized the nursing staff to attach order sets onto charts based on triage assessment and will re-assess with another PDSA cycle after this intervention.
Introduction: Although acute gastroenteritis is an extremely common childhood illness, there is a paucity of literature characterizing the associated pain and its management. Our primary objective was to quantify the pain experienced by children with acute gastroenteritis in the 24-hours prior to emergency department (ED) presentation. Secondary objectives included describing maximum pain, analgesic use, discharge recommendations, and factors that influenced analgesic use in the ED. Methods: Study participants were recruited into this prospective cohort study by the Alberta Provincial Pediatric EnTeric Infection TEam between January 2014 and September 2017. This study was conducted at two Canadian pediatric EDs; the Alberta Children's Hospital (Calgary) and the Stollery Children's Hospital (Edmonton). Eligibility criteria included < 18 years of age, acute gastroenteritis (□ 3 episodes of diarrhea or vomiting in the previous 24 hours), and symptom duration □ 7 days. The primary study outcome, caregiver-reported maximum pain in the 24-hours prior to presentation, was assessed using the 11-point Verbal Numerical Rating Scale. Results: We recruited 2136 patients, median age 20.8 months (IQR 10.4, 47.4); 45.8% (979/2136) female. In the 24-hours prior to enrolment, 28.6% (610/2136) of caregivers reported that their child experienced moderate (4-6) and 46.2% (986/2136) severe (7-10) pain in the preceding 24-hours. During the emergency visit, 31.1% (664/2136) described pain as moderate and 26.7% (571/2136) as severe. In the ED, analgesia was provided to 21.2% (452/2131) of children. The most commonly administered analgesics in the ED were ibuprofen (68.1%, 308/452) and acetaminophen (43.4%, 196/452); at home, acetaminophen was most commonly administered (77.7%, 700/901), followed by ibuprofen (37.5%, 338/901). Factors associated with analgesia use in the ED were greater pain scores during the visit, having a primary-care physician, shorter illness duration, fewer diarrheal episodes, presence of fever and hospitalization. Conclusion: Although children presenting to the ED with acute gastroenteritis experience moderate to severe pain, both prior to and during their emergency visit, analgesic use is limited. Future research should focus on appropriate pain management through the development of effective and safe pain treatment plans.
Introduction: Intravenous insertion (IVI) is identified by children as extremely painful and the resultant distress can have lasting negative consequences. There is an urgent need to effectively manage such procedures. Our primary objective was to compare the pain and distress of IVI with the addition of humanoid robot-based distraction to standard care, versus standard care alone. Methods: This two-armed randomized controlled trial (RCT) was conducted from April 2017 to May 2018 at the Stollery Children's Hospital emergency department (ED). Children aged 6 to 11 years who required IVI were included. Exclusion criteria included hearing or visual impairments, neurocognitive delays, sensory impairment to pain, previous enrolment, and discretion of the ED clinical staff. Primary outcomes were measured using the Observational Scale of Behavioural Distress-Revised (OSBD-R) (distress) and the Faces Pain Scale-Revised (FPS-R) (pain). A total of 426 pediatric patients were screened and 340 were excluded. Results: We recruited 86 children, of which 55% (47/86) were male; 9% (7/82) were premature at birth; 82% (67/82) had a previous ED visit; 30% (25/82) required previous hospitalization; 78% (64/82) had previous IV placement and 96% (78/81) received topical anesthesia. The mean total OSBD-R score was 1.49 ± 2.36 (standard care) compared to 0.78 ± 1.32 (robot group) (p = 0.047). The median FPS-R during the IV procedure was 4 (IQR 2,6) in the standard care group alone, compared to 2 (IQR 0,4) with the addition of humanoid robot-based distraction (p = 0.10). Change in parental state anxiety pre-procedure versus post-procedure was not significantly different between groups (p = 0.49). Parental satisfaction with the IV start was 93% (39/42) in the robot arm compared to 74% (29/39) in the standard care arm (p = 0.03). Parents were also more satisfied with management of their child's pain in the robot group (95% very satisfied) compared with standard care (72% very satisfied) (p = 0.002). Conclusion: A statistically significant reduction in distress was observed with the addition of robot-based distraction to standard care. Humanoid robot-based distraction therapy reduces distress and to a lesser extent, pain, in children undergoing IVI in the ED. Further trials are required to confirm utility in other age groups and settings.
Introduction: Given the current opioid crisis, caregivers have mounting fears regarding use of opioid medication in their children. Since caregivers are often the gatekeepers to their children's pain management, understanding their perspectives on analgesics is essential. For caregivers of children with acute injury presenting to the pediatric emergency department (PED), we aimed to determine caregivers’: a) willingness to accept opioids from emergency care providers, b) reasons for refusing opioids, and c) past experiences with opioids. Methods: A novel 31-item electronic survey was offered, via tablet device, to caregivers of children aged 4-16 years who had a musculoskeletal injury <7 days old and presented to one of two Canadian PEDs between March and November 2017. Primary outcome was caregiver willingness to accept opioids for moderate pain for their children. Results: 517 caregivers completed the survey; mean age was 40.9 +/−7 years with 70.0% (362/517) being mothers. Children included 62.2% (321/516) males with an overall mean age of 10 +/−3.6 years. 49.6% of caregivers (254/512) reported willingness to accept opioids for moderate pain that persisted after non-opioid analgesia, while 37.1% (190/512) were unsure what they would do. Only 33.2% (170/512) of caregivers stated they would accept opioid analgesia upon discharge while 45.5% (233/512) were unsure about at-home use. Caregivers were primarily concerned about side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (OR 1.12, 95% CI 1.01-1.25) and side effects (OR 1.25, 95% CI 1.11-1.42) increased the odds of rejecting opioids in the emergency department, while fears of addiction (OR 1.19, 95% CI 1.07-1.32) and overdose (OR 1.15, 95% CI 1.04-1.27) increased the odds of rejecting opioids for at-home use. Conclusion: Only half of caregivers reported that they would accept opioids for moderate pain, despite ongoing pain following non-opioid analgesics. Caregiver fears of addiction, side effects, overdose, and masking their child's diagnosis influence their behaviours. These findings are a first step in understanding caregiver decision-making and can guide healthcare providers in their conversations about acute pain treatment with families.
Introduction: There is abundant evidence that in children, assessment and pharmacologic treatment of pain by prehospital providers is suboptimal. Most paediatric calls are performed by primary care paramedics who are unable to administer pharmacologic analgesia to children but can administer non-pharmacologic therapies. We sought to describe the proportion of children provided non-pharmacologic analgesia by prehospital providers. Methods: We reviewed all ambulance call reports (ACR) of children age 0-17 years with an acutely painful condition (headache, abdominal pain, possible fracture, head/ears/eyes/nose/throat pain, back pain, and unclassified pain) who were transported to the Children's Hospital, London Health Sciences Centre between 2008 and 2017. We excluded ACRs lacking data pertaining to the primary outcome. Data collection was recorded by two blinded assessors using a study-specific ExcelTM sheet. The primary outcome was the proportion of children offered non-pharmacologic analgesia. We performed a hierarchical stepwise logistic regression on the primary outcome using covariates defined a priori: age, sex, visible deformity, documentation of pain score, and complaint. Results: Of 19782 ACRS, we report the preliminary results of 500 ACRs reviewed from Jan 1 to Feb 22, 2016. Of the 403 ACRs eligible for analysis, the median (IQR) age was 13 (8) years and 174 (43.2%) were females. 309/403 (76.7%) calls involved primary (as opposed to advanced) care paramedics. Pain assessments were performed in 171/403 (42.4%) calls, most commonly the 0-10 verbal numeric rating scale [128/171 (74.8%)] and the median (IQR) score was 7 (4) (n = 128). Non-pharmacologic analgesia was offered in 72/403 (17.9%) of calls, most commonly ice (37/72, 51%) and splint (29/72, 40%). In the multivariate model, significant predictors of non-pharmacologic analgesia included older age (OR 1.1; 95% CI: 1.1, 1.2; p = 0.01) and visible deformity (OR 8.2; 95% CI: 2.5, 30.2; p = 0.001). Sex (p = 0.62), documentation of pain score (p = 0.81), and complaint (p = 0.05) were not significant predictors. Conclusion: In this preliminary analysis, the provision of non-pharmacologic analgesia to children in Southwestern Ontario by prehospital providers was suboptimal despite moderate to severe levels of pain. Less than half of patients had pain assessments documented. There is a clear need for education surrounding pain assessment and non-pharmacologic analgesic options in children among prehospital providers.