There is growing evidence that children have short- and long-term physical, physiological, and psychological effects due to untreated acute pain. Because the majority of children who seek care in an emergency department present with pain or experience pain during the evaluation and treatment in the emergency department, optimal assessment and treatment of pain are paramount for this population. This review will highlight the many complexities of the assessment of pain for the pediatric patient. In addition, a variety of factors that affect the self-report of pain in children will be identified. Optimizing the utility of a pain assessment remains a challenge for the health care provider in the emergency setting. The common goal of a decreased experience of pain for children through improved analgesic administration remains.

Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings.Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model.Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone.Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.

Verbal prehospital reports on an injured patient’s condition are typically used by trauma centers to determine if a trauma team should be present in the emergency department prior to patient arrival (i.e., trauma team activation). Efficacy studies of trauma team activation protocols cannot be conducted without a criterion standard definition for which pediatric patients need a trauma team activation. To develop a consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation. Ten local and national experts in emergency medicine, emergency medical services, and trauma were recruited to participate in a Modified Delphi survey process. The initial survey was populated based on outcomes that had been used in previously published literature on trauma team activation. The criterion standard definition for trauma team activation was refined iteratively based on survey responses until at least 80% agreement was achieved for each criterion. After five voting rounds a consensus-based definition for pediatric trauma team activation was developed. Twelve criteria were identified along with a corresponding time interval in which each criterion had to occur. The criteria include receiving specific surgery types, interventional radiology, advanced airway management, thoracostomy, blood products, spinal injury, emergency cesarean section, vasopressors, burr hole or other procedure to relieve intracranial pressure, pericardiocentesis, thoracotomy, and death in the emergency department. All expert panel members voted in all 5 voting rounds, except 1 member missed rounds 1 and 2. Each criterion had greater than 80% agreement from the panel. A criterion standard definition for the highest-level pediatric trauma team activation was developed. This criterion standard definition will advance trauma research by allowing investigators to determine the accuracy and effectiveness of highest-level pediatric trauma team activation protocols. Qualitative

Background. Pain management for children with musculoskeletal injuries is suboptimal and, in the absence of clear evidence-based guidelines, varies significantly.Objective. To systematically review the most effective pain management for children presenting to the emergency department with musculoskeletal injuries.Methods. Electronic databases were searched systematically for randomized controlled trials of pharmacological and nonpharmacological interventions for children aged 0–18 years, with musculoskeletal injury, in the emergency department. The primary outcome was the risk ratio for successful reduction in pain scores.Results. Of 34 studies reviewed, 8 met inclusion criteria and provided data on 1169 children from 3 to 18 years old. Analgesics used greatly varied, making comparisons difficult. Only two studies compared the same analgesics with similar routes of administration. Two serious adverse events occurred without fatalities. All studies showed similar pain reduction between groups except one study that favoured ibuprofen when compared to acetaminophen.Conclusions. Due to heterogeneity of medications and routes of administration in the articles reviewed, an optimal analgesic cannot be recommended for all pain categories. Larger trials are required for further evaluation of analgesics, especially trials combining a nonopioid with an opioid agent or with a nonpharmacological intervention.

Objectives: Outpatient pain management after acute injuries is an important part of emergency department (ED) care, but there is little evidence to support best practice. Satisfaction with care is one way to assess the effectiveness of current practice. This study describes the outpatient pain experience for children with an arm fracture and explores the variables associated with parents’ dissatisfaction with pain treatment for 2 analgesics after ED care. Methods: As a part of a randomized clinical trial assessing pain treatment after an arm fracture, parents and their children completed daily diaries recording pain scores, function disruption (play, school, sleep, eating), and adverse effects for 3 days after discharge from the ED. Parents and children also completed the Total Quality Pain Management Instrument on the third day to assess pain experience. Parents’ satisfaction was defined with an arm fracture lowest reported satisfaction during the study period. Results: A total of 244 children with complete diaries were analyzed. More than half of children reported pain at home that was present “all the time” or “quite a bit.” Thirty-two percent of parents were not satisfied with home pain treatment for their child. Parents’ dissatisfaction was strongly associated with inadequate pain relief. It was also independently associated with nausea, disruption in play and sleep, and increased doses of medication. Discussion: Children with arm fractures experience noteworthy pain in the outpatient setting. Parents’ dissatisfaction with home pain management for children suggests that more research is needed to evaluate the factors that result in improvements in both parent and child satisfaction and the most effective way of producing those changes.