{"version":1,"type":"rich","provider_name":"Libsyn","provider_url":"https:\/\/www.libsyn.com","height":90,"width":600,"title":"Ouch-less Pediatrics","description":"Ouch-less Pediatrics Safely and effectively managing pain in our pediatric patients is a primary responsibility for our EMS clinicians. Medical directors must be able to identify gaps in pediatric pain management and provide the necessary QA\/QI to close those gaps. In this episode we focus on exactly that, with several experts in EMS joining us to offer their knowledge and critical appraisal of the evidence in order to identify and close the gaps in the management of pain in children. Brought to you by: Dr. Joelle Donofrio-Odmann and Dr. Joseph Finney     Take Home Points Medical Directors can utilize QA\/QI to improve management of pediatric pain within their EMS systems. Protocols for managing pediatric pain benefit from mirroring the most current evidence. This podcast provides information on how to develop protocols, what QA\/QI to consider, the current evidence to optimize your ouch-less EMS agency, and how to use your tertiary Children\u2019s hospital to help. Below are all the tools you need to make your agency \u201couch-less\u201d. The NASEMSO Model Guidelines are also a great option to help guide protocol development (link below). DON\u2019T WAIT TO TREAT PAIN! https:\/\/nasemso.org\/projects\/model-ems-clinical-guidelines\/ We also recommend utilizing the EIIC Pain management resources available at the link below.  The EIIC has educational resources, tools, and recommendations for improving pediatric pain management.   https:\/\/emscimprovement.center\/education-and-resources\/toolkits\/pediatric-pain-management-toolkit\/   Literature Review Recap   Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department. Published in The Journal of Emergency Medicine in 2020   Where: Assessment of the management of pediatric pain in a tertiary children\u2019s hospital emergency department in the setting of long bone fractures.   What: Retrospective single center study   Who: Age 18yo and younger with ED diagnosis of long bone fracture, 2005-2016 905 patients included 63% male 48% African American Median age 6yo 72% fracture in upper arm, 77% sent home   Outcome: 28% received no pain medication Median time to document a pain score was 6 minutes Pain medication order time was 63 minutes 87 minutes to time of administration of pain medications Factors related to undertreatment African American children Public insurance Single fracture POV arrival to ED Factors related to faster treatment Arriving when ED is busier Private insurance Lower extremity fracture EMS arrival to ED Implications: Even in the ED, we don\u2019t do a very good job of quickly treating pain or even treating it at all.   Consider standing orders for managing pain in certain situations such as long bone fractures.   Prehospital Pain Management: Disparity By Age and Race published in Prehospital Emergency Care in 2018   Where: Research data set   What: Retrospective descriptive study from 2012-2014   Who: Patients <18yo captured in the database   Outcome: > 69 million EMS activations, 276,925 were for patients transported with primary impression of fracture, burn or penetrating injury.  6% of EMS activations with these potentially painful medical impressions received any pain meds and this was lowest in amongst infants and toddlers where it was only 6.4%.   The most administered meds were Morphine and fentanyl.  < 7% of children age < 11 received either med.  Only 29.5% had pain documented as a symptom Significantly lower amongst infants and toddlers at 14.6%.    When pain was documented as a symptom, only 19.9% received pain medication (only 68% of infants and toddlers vs. 26.4% of children aged 11-14) To examine racial disparities, patients were grouped by age < 15 and > 15yrs of age.   Administration of pain medications varied significantly amongst racial groups.  Black patients were the least likely to be administered pain medication (8.7%) while white patients were the most like (22.4%).  This disparity held for both age groups.   Implications: There is likely bias leading to disparities in the management of pain prehospital both by age and race.   Consider establishing protocols for pain management especially in our youngest patients. QA and QI focused on bias in prehospital medicine is critical for medical directors.         Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children published in Prehospital Emergency Care in 2016   Objective: Assess the change in frequency of pain documentation and the change in frequency of opioid administration in kids with injuries after applying evidence-based guidelines   Where: 3 separate EMS agencies, part of CHAMP research node of PECARN   Who: <18yo prehospital patients with blunt, penetrating, laceration, and\/or burn trauma   What: Updated pain protocols and implemented mandatory CE   Outcome: No improvement after implementation of evidence-based guidelines for managing pain 3600 pre and 3700 post intervention Opioid administration pre\/post remained 5% (15% if moderate to severe pain score 4 or higher) 18% had pain score documented pre\/post (75% moderate to severe pain) Only one agency gave intranasal opioids despite all three agencies having the capability No implementation of QI protocols along with these changes   Implications: Implementation of protocol changes alone does not translate to clinical practice change. If you make changes \u201cyou really have to own it\u201d   Consider adding quality improvement projects to improve adherence to protocol changes. Robust QA\/QI is a must for any medical director. Measuring an intervention over time before deciding if they worked or not helps to avoid false results during the "washout period". Consider an EMR prompt to encourage assessing and treating pain.   Evidence-Based Guidelines for Prehospital Pain Management: Recommendations published in Prehospital Emergency Care in 2021   Objective: Provide evidence-based guidelines for the management of pain prehospital in adults and pediatrics   What: RECENT Systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ) with funding by NIHTSA.   (Mostly) Pediatric-focused Recommendations   Intranasal fentanyl is preferred over IM\/IV fentanyl for prehospital pain management in pediatrics. Don\u2019t delay for IV access. IV acetaminophen is preferred over IV opioids for the management of moderate to severe pain IF it is available IV NSAIDs or IV opioids is appropriate for initial prehospital pain management. IV NSAIDS are preferred over IV acetaminophen, also consider PO for both. IV ketamine or IV NSAIDs for initial pain management prehospital is appropriate IV ketamine or IV opioids for initial pain management prehospital is appropriate If IV opioids are selected for prehospital pain management, Morphine or fentanyl are preferred Avoid mixing opioids and ketamine IV   Implications: Follow evidence-based guidelines when developing your pediatric pain management protocols  Don't Forget: Don\u2019t forget intranasal options and be careful when mixing IV ketamine and IV opioids If administering sedating medication to pediatric patients, ALWAYS use ETCO2. Implement both non-pharmacologic and pharmacologic pain treatments into EMS protocols.   For pharmocologic treatments, have both opioid and non-opioid options available. Have PO meds as well as IN, IM and IV options. Teach your medics how to document and treat pain.  Disclaimer The Emergency Medical Services for Children Innovation and Improvement Center is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award (U07MC37471) totaling $3M with 0 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.     To learn more about the Emergency Medical Services for Children Innovation and Improvement Center visit https:\/\/emscimprovement.center   Email km@emscimprovement.center Follow on Twitter @EMSCImprovement   Sources: International Association for the Society of Pain Subcommittee on Taxonomy  WT Zempsky NL Schechter 2003 What\u2019s new in the management of pain in children Pediatrics Rev 24 10 337 347 16  SJ Weisman B Bernstein NL Schechter 1998 Consequences of inadequate analgesia during painful procedures in children Arch Pediatrics Adolescent Med 152 2 147 149 17  JT Pate 1996 Childhood medical experience and temperament as predictors of adult fu Educational Module on Prehospital Pain Management in Children (Targeted Issues Grant): http:\/\/www.youtube.com\/watch?v=Tn3MF_4-9iQ&feature=youtu.be Lorin R. Browne, Manish I. Shah, Jonathan R. Studnek, Daniel G. Ostermayer, Stacy Reynolds, Clare E. Guse, David C. Brousseau & E. Brooke Lerner (2016) Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children, Prehospital Emergency Care, 20:6, 759-767, DOI: 10.1080\/10903127.2016.1194931 ","author_name":"The Pediatric EMS Podcast","author_url":"https:\/\/sites.libsyn.com\/414020","html":"