Assessment of pain and anxiety related to painful medical procedures in pediatric oncology

In this article we review the instruments most commonly used in clinical practice and research to assess the pain and anxiety experienced by children with cancer undergoing painful medical procedures. Issues such as the prevalence of pain in childhood cancer, the psychologic impact of medical procedures in children, and the efforts some institutions are making to implement pediatric pain assessment programs are also reviewed, bearing in mind that pain is a subjective and multidimensional experience. Behavioral measures, self-reports, multidimensional assessment tools and physiological measures are included, emphasizing the importance of self-reports, which are considered the gold standard in pediatric pain assessment. This literature review indicates the need for research and for the education of health care professionals in pediatric pain assessment. Finally, recommendations for pediatric pain assessment are suggested.     

Assessment of pediatric patients by emergency medical technicians-basic

OBJECTIVE: To determine whether emergency medical technicians-basic can accurately assess children and whether this ability varies with the patient's age or diagnosis. This determination is important for educational program design for emergency medical technicians in pediatrics and for evaluation of the possibility of expanding their scope of practice. DESIGN: Retrospective chart review. SETTING: Pediatric emergency department in a large, urban hospital. PARTICIPANTS: Patients (n = 2430) presenting to the pediatric emergency department via basic life support ambulance during a 12-month period. MEASUREMENTS: Data collected were name, age, field assessment (FA), and emergency department (ED) diagnosis. Patient's ages were organized into five groups: infant (0-1 y), toddler (1-3 y), preschool (3-6 y), school-aged (6-11 y), and adolescent (> 11 y), and the ED diagnoses were divided into seven categories. The accuracy of the FA was compared with the ED diagnosis. We then analyzed FA accuracy by patient's age and type of diagnosis. The chi(2) contingency table analysis was used for dichotomous variables (P < 0.05). In addition, logistic regression and stratified analysis were used. Both ambulance and hospital charts were available for 2064 patients. Age ranged from birth to 19 years with a bimodal distribution at the extremes of patient age and a mean age of 8.25 (SD, 5.64). The distribution was 11.7% (241) infants, 14.7% (303) toddlers, 14.9% (307) preschool, 21.2% (437) school-aged, and 37.6% (776) adolescents. RESULTS: Overall emergency medical technician-basic assessment was accurate 81.5% (1683) of the time. There was a statistically significant variation in accuracy with both age group (chi(2) = 40.07, P < 0.05) and diagnostic category (chi(2) = 185.7, P < 0.05). By age group, the accuracy of field assessment was 69.7% (168) infants, 75.9% (230) toddlers, 82.7% (254) preschool, 86.7% (379) school-aged, and 84.0% (652) adolescents. By category of diagnosis, the accuracy of the field assessment was 92.4% (292) major trauma, 91.4% (478) minor trauma, 88.9% (112) psychologic and social, 85.1% (229) major medical, 81.1% (180) wheezing-associated respiratory illness, 65.4% (350) minor medical, and 57.5% (42) non-wheezing-associated respiratory illness. CONCLUSIONS: Emergency medical technicians-basic were highly successful in assessing children with wheezing, serious illness, injuries, and psychologic and social conditions. Consideration should be given to expanding their scope of practice in these areas. They were less successful in assessing minor medical conditions and respiratory emergencies other than wheezing. They require additional training in these areas.     

Predictors of pediatric emergency patients discharged against medical advice

Based on a retrospective 5-year medical record review, this study characterizes factors associated with patients discharged against medical advice (AMA) from a tertiary pediatric emergency department (ED) and compares rates of return to the ED and admission to the hospital with those of patients routinely discharged. Data from 94 patients discharged AMA are compared with those of 188 control patients. Pediatric patients at risk for discharge AMA are older than 15 years (odds ratio [OR], 3.561; 95% confidence interval [CI], 1.695-7.482), self-register independent of a parent (OR, 3.100; 95% CI, 1.818-152.770), arrive by ambulance (OR, 2.761; 95% CI, 1.267-6.018), involve a consultant (OR, 2.592; 95% CI, 1.507-4.458), and have a chief complaint of abdominal pain (OR, 3.095; 95% CI, 1.154-8.303). Negative predictors include urgent triage (OR, 0.155; 95% CI, 0.039-0.618), a chief complaint of upper respiratory tract illness or otitis media (OR, 0.229; 95% CI, 0.075-0.702), and discharge diagnoses of infection (adjusted OR, 0.053; 95% CI, 0.004-0.767), disease of the nervous system and sense organs (adjusted OR, 0.066; 95% CI, 0.005-0.898), respiratory illness (adjusted OR, 0.072; 95% CI, 0.007-0.718), and gastrointestinal disease (adjusted OR, 0.050; 95% CI, 0.006-0.419). Certain key elements of discharge AMA are well documented, including consequences of discharge AMA (74.5%) and instructions for care (54.3%). Other elements such as alternative therapies (1.1%) are poorly documented. Patients discharged AMA have a significantly higher return rate (24.5%) within 15 days compared with patients who have routine discharge (6.4%) (chi2=18.85, P<.001). Ninety-six percent of patients who return to the ED have the same chief complaint at both visits if discharged AMA compared with 50% of patients who are discharged routinely (P=.003), with 25% admission rates at the time of second visit for both types of discharges. Adolescents who register themselves are at increased risk for discharge AMA. Patients who are triaged as urgent or nonurgent or who have minor illnesses are likely to be dispositioned routinely. Patients discharged AMA are more likely to return to the ED with the same complaint than patients who are routinely discharged.     

Managing pain in the pediatric emergency department

In summary, it is common to encounter children in pain in the pediatric ED. It is often impossible to avoid inflicting pain on some children in the ED. The proper management of this pain is thus essential. This management should be accomplished with a variety of narcotic and nonnarcotic analgesics, as well as local and topical anesthetics. Other agents such as nitrous oxide, and techniques such as hypnosis and transcutaneous nerve stimulation, have a more limited role in pain management. Gentle restraint and reassurance are of paramount importance.     

Unusual cause of abdominal pain in pediatric emergency medicine

Atypical manifestations of acute hepatitis A virus (HAV) infection include ascites, pleural effusion, acute renal failure, aplastic anemia, and neurological manifestations. Although association of HAV and acute cholecystitis is known, presentation of hepatitis A infection with acute cholecystitis has not been reported in pediatric emergency medicine literature. Primary acute acalculous cholecystitis in children is rare and commonly attributed to systemic infections. We report a case of a child developing acute viral cholecystitis as a presenting feature of sporadic HAV infection and review HAV-associated cholecystitis in children. The article provides a brief illustration of evaluating acute abdominal pain in older children in the emergency department in a developing country.     

Diagnosing abdominal pain in a pediatric emergency department.

We undertook a prospective study of 377 children (two to 16 years old) presenting with abdominal pain to determine: 1) common discharge diagnoses; 2) what signs and symptoms are associated with appendicitis; and 3) follow-up of patients discharged from the emergency department (ED). Nine diagnoses accounted for 86% of all diagnoses made. The most common final diagnosis was "abdominal pain" (36%). The following findings were significantly associated with appendicitis: vomiting, right lower quadrant(RLQ) pain, tenderness, and guarding (all P less than 0.001). Ninety-seven percent (28/29) of patients with appendicitis had at least two of these four signs and symptoms, as did 28% (96/348) of patients without appendicitis. The sensitivity of the model is 0.96, and the specificity is 0.72 (positive predictive value = 0.24; negative predictive value = 0.99). Of the patients contacted within one week of the visit (237), 75% reported that the pain had resolved (mean contact time, 2.6 days). We conclude that 1) patients presenting to the ED with abdominal pain often leave with the diagnosis of abdominal pain; 2) of the patients contacted, the majority reported that their pain has resolved; and 3) a diagnosis of appendicitis should be considered in any patient with any two of the following signs or symptoms: vomiting, guarding, tenderness, or RLQ pain. Such patients should be evaluated and observed carefully for the possible diagnosis of appendicitis.     

急诊科小儿镇痛和镇静的研究进展

小儿急诊治疗时常伴有外伤或疼痛.在急诊诊治期间,可能有必要进行某些疼痛或令人不适的诊疗操作.临床上需要急诊科医生为小儿提供安全、有效的镇痛和镇静.为此,我们对国外已发表的相关研究结果做一综述,主要包括以下几个方面:确保在急诊时小儿不会经受长时间或额外的疼痛;使用综合评估工具评估疼痛以分诊患儿;选择适当的药物、剂量和途径,在首次疼痛处理时即提供有效镇痛;尽可能选择无痛苦的方式给药(经鼻、调味糖浆)等;经常再次评估疼痛分数以确保有效镇痛,并留有足够时间来等待药物起效,同时使用非药理和药理的模式镇痛;避免"常规"进行一些不必要的致痛的侵入性操作;使用表面麻醉、局部麻醉和区域麻醉连同适当的安全程序镇静,以避免疼痛加剧.     

儿科急诊医务人员培训体系建设

儿科急诊医学发展的关键在于培养专业人才.本文简要介绍美国等发达国家儿科急诊医护培训体系,分析我国存在的主要问题,提出发展建议.     

Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic

The aim of this study was to assess the epidemiology of chest pain among unselected Belgian children referred to an emergency department or to a cardiology clinic. MATERIAL AND METHODS: We analyzed the etiology to chest pain and the diagnostic workup of 168 consecutive pediatric patients, seen in our emergency department with the primary diagnosis of chest pain over a 5-year period (group A). Simultaneously a sample of 69 consecutive pediatric patients referred to the cardiology clinic by primary care physicians with the same chief complaint was prospectively included in the study (group B). RESULTS: Chest wall pain was the most common diagnosis in the group A (64%). Other causes included pulmonary (13%), psychological (9%), cardiac (5%), traumatic (5%), and gastrointestinal problems (4%). The organic causes were easily identified or suspected by history and physical examination. Chest radiography, electrocardiography, and blood analysis were performed in most patients with suspected nonorganic chest pain but in no case were organic diseases diagnosed by those ancillary studies. In group B, chest wall pain was also the most common diagnosis (89%). Supraventricular tachyarrhythmia and exercise-induced asthma were demonstrated in 5 (7%) and 3 patients (4%), respectively. The most important tools in assessing a child with acute chest pain in an emergency department are thorough history and physical examination. Assessment of recurrent chest pain is more difficult; arrhythmia, and allergic and exercise-induced asthma may be underestimated when investigations are not performed.     

Prehospital evaluation of non-transported pediatric patients by a large emergency medical services system.

OBJECTIVES: 1) To determine whether demographic characteristics of prehospital pediatric patients evaluated, but not transported, by emergency medical services (EMS) personnel were different than those of transported patients in a large metropolitan area, 2) to determine whether chart documentation for non-transported (NT) patients by EMS personnel varied among paramedic and ambulance units, and 3) to describe the most common complaints of pediatric non-transported patients. METHODS: We conducted a cross-sectional study of children 12 years of age and less who were evaluated, but not transported, by EMS personnel over a 1-year period. We incorporated a nested case control study, comparing the demographic and presenting characteristics of the NT and transported children (eg, age, gender, ethnicity, and time of day). Among NT patients, significant elements of chart documentation as completed by personnel on paramedic versus ambulance units were compared. Chief complaints of the NT children were described. RESULTS: During the study period, 3057 patients met inclusion criteria for cases, and 12,302 met the criteria for controls. Non-transport was less common in the first two years of life, among Hispanic patients, and during the hours of midnight to 6 am. Among NT patients, personnel of paramedic units had significantly better documentation of contact with on-line medical command (OLMC) (52% vs. 33%) than did personnel of ambulance units. Injuries (27.7%), motor vehicle accidents (20.4%), and choking episodes (10.2%) were the most common complaints among NT patients. CONCLUSIONS: In this large metropolitan population, non-transport was less common in children under 2 years of age and during the early morning hours. Hispanic children were more likely to be transported. Ambulance units were significantly less likely than paramedic units to document contact with OLMC. Injuries were the most common complaints of pediatric NT patients.     

Behavioral approaches to anxiety and pain management for pediatric venous access

Pediatric venous access causes unnecessary anxiety and pain in children and, in turn, can have detrimental consequences. Behavioral approaches to pediatric venous access distress management can be organized temporally. Specifically, preparation before the procedure includes providing children with sensory and procedural information in an age-appropriate manner and providing training in coping skills. It is important to consider the timing, format, and content of the approach to provide optimal preparation for the unique circumstances of the individual patient. In addition to the child patient, preparing parents and teaching them which specific behaviors might be most helpful to their child should prove valuable to both patient and parents. During the procedure, there are benefits to providing secure and comfortable positioning. In addition, researchers recommend that adults encourage children to cope and actively engage children in distracting activities. For infants, there is support for the distress-mitigation properties of swaddling, skin-to-skin contact, breastfeeding, and sucrose. After venous access, distraction and encouragement of coping should speed recovery. In sum, research in behavioral approaches to pediatric pain management has provided recommendations for minimizing children's anxiety and pain associated with venous access.