Ada Holak
Doctorate
Doctorate Title: Analysis of methods of treating acute pain in children by medical rescue teams.
Doctorate Description:
Introduction
In order to be able to effectively treat children after injuries, pain should be treated as the fifth vital parameter, just like the others (heart rate, respiration, blood pressure, temperature) requiring measurement, monitoring and modulation of values. There are many tools available to evaluate pain in children at all stages of their development. There are numerical, verbal, facial and behavioral scales to choose from, based on the observation of behavior, which can be used already at the pre-hospital stage, during EMTs interventions. Treatment of acute pain in children requires not only pharmacotherapy but also supportive methods such as cooling and immobilization. The best results are achieved by a combination of analgesia, sedation and non-pharmacological pain relief methods.
Objective of the work
The main aim of the presented study was to assess the frequency, quality and methods of treating acute post-traumatic pain in children at the pre-hospital stage, based on the analysis of medical records contained in Patient Care Reports (PCR) from interventions carried out by two types of Emergency Medical Teams (EMT): Primary (EMT P - without doctor in a crew, only paramedics) and Specialistic (EMT S - with doctor in the crew). The study was to answer questions about the frequency of using pain intensity scales (with numerical or behavioral choice and its impact on the team's therapeutic decisions), the use of pharmacotherapy or other non-pharmacological methods of pain modulation. The research material was divided into two periods relative to the amendment to the Act on Patients' Rights and Patient Ombudsman before and after. The aim was to compare whether the introduction of a top-down system change had an impact on increasing the quality of services provided.
Material and methods
The study was retrospective and included 2,452 PCR from the interventions of the EMTs in the operational region covering 5 operative regions in the Mazovian District. PCR cards are medical documentation filled in by the managers of the EMTs, both P and S on duty in the National Polish Resque Medical System, after interventions with children. The patients enrolled in the study were in the age range from 1 month to 18 years of age. PCR with the diagnosis of trauma according to International Classification of Disease 10 (ICD 10) were selected from the following groups: S 00 to S 99 (diagnoses including: head, neck, chest, abdomen, lower back, lumbar spine and pelvis, shoulder and arm, elbow and forearm injuries, wrist and hand, hips and thighs, knees and shins), from T 00 to T 32 (injuries: numerous parts of the body, undefined parts of the torso, limbs and body area, the effects of a foreign body penetrating through natural body openings, thermal and chemical burns , frostbite) and from T 90 to T 98 (consequences of injuries, poisoning and other effects of external factors, including animal bites). When defining the research protocol for each patient, the following information was taken into account: 1. General: mechanism of the injury, place of the event, gender and age of the patient, decision to transport to the hospital, 2. on the study of basic vital signs, 3. concerning treatment: use of a pain rating scale, pharmacotherapy along with the route of administration and possible complications, immobilization, cooling.
Results
EMTs most often provided assistance to boys from the age groups of adolescents and school children, injured as a result of low-energy injuries, which occurred at home or school. The least frequent category were EMTs called for infants and for road traffic accidents. In only 1% of cases the children had pain assessed on a numerical scale (the behavioral scale was not used at all). The frequency of pain evaluation was not influenced by such factors as age, sex, place of the event, or even incorrect values of vital parameters for a given age group. In the group where pain was assessed using a numerical scale, 55% of EMTs administered analgesic treatment to patients. The assessment of pain statistically more often resulted in the choice of drugs such as: ibuprofen, morphine and fentanyl. Morphine and paracetamol were most often used in children with burns (40% and 29%). This mechanism of trauma also influenced the increased supply of benzodiazepines and ibuprofen. Interestingly, the opioid of choice for the treatment of burns is morphine, and fentanyl was not used on any occasion. Analgesics (paracetamol, metamizole) and benzodiazepines (midazolam, diazepam) were administered more often to children after injuries by EMT S than by EMT P. EMT S was most often used for high-energy injuries and burns, and P was most often used for low-energy injuries. A very high percentage of patients with low and high energy injuries (84.4% and 83.5%, respectively) did not receive any analgesia. The vast majority of trauma patients (70%) were transported to the hospital, mainly by EMT P (over 70%). Children most often transported to the hospital had suffered burns (84%). In a statistically significant manner, cooling was used in the case of burns (63%). There was a statistically significant increase in the frequency of using pain rating scales and the frequency of administration of drugs such as paracetamol and fentanyl in trauma patients who had already been treated after the amendment to the Act on Patients' Rights and Patient Ombudsman, compared to the period preceding this amendment.
Conclusions
1. Both P and S EMTs generally do not assess pain intensity in pediatric patients using pain evaluation scales. In individual cases, they use numerical scales. Behavioral scales are not used.
2. In the treatment of traumatic pain, opioids are equally often used by both types of EMT (P and S), while multimodal therapy of post-traumatic pain in children is more often used by EMT S.
3. The decision about the supply of analgesics in children with post-traumatic pain is mainly influenced by the mechanism of the injury (burn). It is not influenced by factors such as: the patient's age (excluding the group of infants), the decision to transport to the hospital or leave at the scene of the event, the values of vital parameters beyond the limits of the norms adopted for a specific age range.
4. The group of patients best protected against pain are small children after burns, who often use analgosedation combined with cooling.
5. Cooling is an activity undertaken by EMTs only for burn patients. It is not used to treat other injuries.
6. The amendment to the Act on Patients' Rights and Patient Ombudsman, emphasizing the importance of analgesic treatment, had a minimal effect on increasing the frequency of pain evaluation in injured children and the frequency of administration of analgesics such as fentanyl and paracetamol.
Details:
Type: PhD
University: Wroclaw Medical University
Primary Supervisor: Professor Marzena Zielinska
Category: Children
Funding:
Start Date: 2018
End Date: 2020
Status: Complete
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