I Have an Owie!!!

Acute pain in the pediatric patient population is a frequently encountered clinical issue and presenting symptom. Prompt attention to, assessment of, and management of a pediatric patient’s pain are critical in order to enable providers to carry out the necessary diagnostic evaluation and enact the appropriate therapeutic interventions in a timely fashion. This also allows for rapport building between the provider and patients and engenders more trust, compassion, and benevolent care. The pediatric population is unique, both physiologically and developmentally, and therefore, approaches to management of acute pain in these patients must be unique as well. This chapter addresses and discusses assessment of acute pain, including pain scores, and modalities for control of acute pain in pediatric patients.

FOOSH—OUCH!

A twelve-year-old boy presents with right wrist pain after a fall onto outstretched hand (FOOSH). The injury was isolated to the right wrist, which was swollen, visibly deformed, but neurovascularly intact distally. Imaging revealed a distal radial and ulna fracture with dorsal displacement. Injuries after a FOOSH include physeal fractures, incomplete fractures, supracondylar fractures, and soft-tissue injuries. Open fractures and neurovascular compromise warrant emergent orthopedic consultation. Displaced fractures should be reduced in the ED and immobilized in a sugar tong splint. Local anesthetics and procedural sedation are important tools to relieve pain and improve patient cooperation. Due to the risks of sedation, physicians should have a systemic approach to evaluate the patient and prepare the monitoring and airway equipment. There are many different medications and routes available. It is important for the physician to be aware of the side effects and discuss this with the patient and parents.

It’s “Nap” Time!

Pediatric sedation is a useful tool in the emergency department to help safely manage patients’ pain and anxiety, while performing necessary diagnostic and therapeutic procedures. As sedation is not entirely without risk, the healthcare provider may try alternative methods, such as distraction and pain control, prior to resorting to sedation. However, when those methods are inadequate, sedation may be necessary. There are a number of factors to keep in mind to safely conduct a sedation in the emergency setting. This chapter covers the candidacy of pediatric patients for sedation, the monitoring during and after sedation, and some of the commonly used agents for a short sedation.

What a Pain in the Neck!

The chapter on cervical spine controversies in children describes what initial steps need to be taken in assessing a pediatric patient with neck pain after trauma, and discusses the decision-making process that goes into further evaluation and testing. Clinical actions and assessments of the patient on-scene, whether to pursue imaging once in the emergency department setting, and what imaging is most appropriate depending on the patient presentation are discussed. Indications and contraindications for cervical spine immobilization and spinal positioning, including proper techniques based on a patient’s age and whether or not such steps are necessary. It also discusses the pros and cons of x-rays, CT scans, and MRIs in the context of pediatric neck trauma, and current guidelines that should be followed when deciding to order such studies.

The Neverending Ouch

Chronic pain is defined as pain that is either persistent (ongoing) or recurrent (episodic) and is thought to be multifactorial, involving biological, psychological, and sociocultural factors. Generally, pain is considered chronic when the pain itself or recurrent episodes of pain persist greater than 3 to 6 months. Assessing children’s pain can be challenging, and validated tools should be used such as the Wong-Baker FACES Pain Rating Scale or the OUCHER Pain Scale (younger children) and verbal numerical scales (older children). Following assessment, treatment can be initiated based on the severity, nature, and presumed etiology of the pain. Management of acute or chronic pain episodes should follow evidence-based recommendations, which include both pharmacological and nonpharmacological principle. A stepwise escalation in pain medication may be required to adequately control the patient’s pain.

Clavicle Fracture! Simple! Not So Much!

Simple clavicle fractures are common and may be easily managed by primary care providers as well as acute care providers. Most sternoclavicular (SC) joint dislocations occur from higher energy motor vehicle accidents or sports trauma, with anterior fracture/dislocations more common than posterior. Although uncommon, they may be associated with devastating complications including great vessel and/or trachea injury, dyspnea, hoarseness, dysphagia.

The Rocking Pelvis

This chapter reviews the pelvic and genitourinary physical examination in the setting of pelvic trauma, the types of pelvic fractures, and diagnostic tests available, including ultrasound, plain radiography, and computed tomography, to evaluate for pelvic injuries. It discusses the management principles of fluid resuscitation and hemorrhage control with an unstable pelvis, including consideration of consultation with trauma surgery, orthopedic surgery, and interventional radiology. It examines the types of concomitant injuries that may be expected, including splenic, hepatic, urethral, and rectal injuries and emphasizes the need for individualized workup and management for each patient based on a thorough physical examination. The indications for a retrograde urethrogram and treatment options for pelvic fractures are also briefly reviewed.

Who’s Doing the Twist?

Fractures are common accidental and nonaccidental injuries. It is the job of the physician to be able to gather the necessary historical information, place the injury in developmental context, and identify and recognize abusive injury patterns. It is important to consider the age and development of the child paired with the history, location, type, and mechanism of the injury. Further workup may be needed in cases of suspected child maltreatment with physical abuse to look within and beyond the skeletal system for additional injuries such as neurologic and gastroenterological in nature. It is imperative to consider insufficient nutrition and genetic causes as differential diagnoses for fractures.

Where Do These Puzzle Pieces Go?

Pediatric elbow films can be challenging: What is normal versus abnormal? It is critically important to understand the normal development of the elbow and how to identify normal ossification centers and any fractures. Skeletal differences occur due to age and sex, and the relationship between landmarks can help distinguish what is truly an injury versus a normal developmental variant. In this chapter we review methods to review pediatric plain radiographs to identify pediatric elbow fractures, particularly supracondylar humeral fractures.

Down a Slippery Slope

Trauma is the most common cause of morbidity and mortality in the pediatric population. Although chest trauma represents less than 10% of all pediatric traumas, it accounts for 14% of all pediatric trauma-related deaths. Thoracic trauma includes injuries to the chest wall, lungs, heart, tracheobronchial tree, diaphragm, and aorta. The most common injuries include pneumothorax, hemothorax, pulmonary contusion, and rib fractures. Sternal fractures occur less commonly and may be seen in cases of isolated or severe chest trauma. Although chest trauma may result from a direct force and therefore result in an isolated injury, when present, it is most often secondary to an extreme mechanism and associated with other clinically significant injuries.