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2011

Pediatric pain assessment and management : determining baseline provider behaviors in the prehospital setting Rachael Ann Kohntopp The University of Toledo

Follow this and additional works at: http://utdr.utoledo.edu/graduate-projects Recommended Citation Kohntopp, Rachael Ann, "Pediatric pain assessment and management : determining baseline provider behaviors in the prehospital setting" (2011). Master’s and Doctoral Projects. Paper 348. http://utdr.utoledo.edu/graduate-projects/348

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Pediatric Pain Assessment and Management: Determining Baseline Provider Behaviors in the Prehospital Setting

Rachael Ann Kohntopp The University of Toledo 2011

ii Dedication This project is dedicated to my family and friends, including Professor Sharon Gentry, PA-C, all of whom have supported me throughout the past 27 months as a physician assistant student. Without them, I would have never recognized my own strength and desire that it takes to become a professional, skilled, and dedicated physician assistant.

iii Acknowledgements I would like to acknowledge the Lucas Country Emergency Medical Services who assisted in the data collection project. I would also like to acknowledge the advisers who have supported and assisted this project to its finish: former trauma research coordinator Heather Stomaugh, BS, CCRP; trauma nurse adviser Rochelle Armola, RN, MSN, CCRN; and former interim trauma research coordinator Nilgun Sezginis, MPH, RHIA, CCS-P.

iv Table of Contents Introduction ......................................................................................................................................1 Literature Review.............................................................................................................................3 Methods............................................................................................................................................7 Results ............................................................................................................................................10 Discussion ......................................................................................................................................13 Conclusion .....................................................................................................................................17 References ......................................................................................................................................18 Tables .............................................................................................................................................21 Figures............................................................................................................................................24 Abstract ..........................................................................................................................................25

1 Introduction After a traumatic injury, pain is inevitable, and the underlying pathophysiology is now extremely well understood. However, the epidemiology of pain is greatly unknown when it comes to acute traumatic injuries. As the most common reason for any patient to seek medical care, pain and its complications are directly associated with a patient’s morbidity and mortality (McLean, Maio, & Domeier, 2002). This is especially true in children; the evaluation of pain and subsequent relief in the prehospital setting is often used as a relative measurement of the outcome of their condition. Emergency medical services (EMS) are at the frontline of acute patient care, and therefore have the most significant impact on pain management in children (Deschamp, 2006). According to the National Association of EMS Physicians (NAEMSP), the primary goal for all EMS teams should be to provide immediate relief of pain and suffering. Although many challenges face the EMS providers when addressing the complex needs of children, the NAEMSP also has stated that every EMS should follow a clinical care protocol to improve clinical results (McLean, Maio, & Domeier, 2002). Pain control should be re-evaluated throughout time as medical care and interventions are constantly changing and improving. The value of continuing education within the medical field is the key to excellent patient care, and holds true for EMS providers in approaching pain management in pediatric trauma patients (Hennes, Kim, & Pirallo, 2005). Through a thorough analysis of current literature, the consensus is that pain assessment, management, and documentation are each vital components within the care of children during the transition from the prehospital environment to the emergency department. Proper systematic training, continuing education, and protocols may improve the experience for the child and other parties involved. It is predicted in this study that preliminary statistics evaluating the assessment,

2 documentation, and management of pain in the prehospital setting will suggest inadequacies. Investigators from Toledo Children’s Hospital pediatric emergency center, in cooperation with Lucas County Emergency Medical System (LCEMS), have completed a preliminary analysis of prehospital management of pain in acute pediatric trauma cases.

3 Literature Review Trauma is the leading cause of death of children in the United States. The most common complaint of any patient presenting in the prehospital setting is pain. Although the assessment and management of pediatric patients in the prehospital setting differs greatly from that of adults, one of the main goals remains the same: to control pain (Huang & Sheehan, 2009). It can be challenging to identify the true presence and severity of pain in pediatric patients, especially in emergency situations. However, the current literature offers a variety of assessment tools based on cognitive ability that have been shown to accurately increase the evaluation and treatment of pain in children of all ages (Strange, Ahrens, Schafermeyer, & Wiebe, 2009). Evaluation and intervention of pain has recently been emphasized by the World Health Organization (WHO) and International Association for the Study of Pain (IASP): “the relief of pain should be a human right” (Baxter & Cohen, 2009). Over the last 20 years, the handling of pain in pediatric patients has evolved into an improved systematic approach in order to ensure the child’s comfort and ease (Zempsky & Cravero, 2004). Around the age of 18 months, a child may have already acquired various words for expressing pain. Children as young as 3 or 4 years old may be able to give specific information about his or her pain (Strange et al., 2009). However, there is still a lack not only in the recognition and use of interventions to control discomfort, but also the documentation of such management (Izsak et al., 2008). Emergency medical technicians are typically the first line of medical contact for a trauma patient before reaching the hospital. Adequate assessment of a patient, especially a young child, can be difficult, and many barriers may face the care provider. Due to the complexity of assessing a child’s pain, proper tools and appropriate intervention should be standardized and utilized more often in the prehospital environment. “In order to remain excellent providers, we must

4 periodically refresh ourselves on the keys of pain management – particularly for pediatric patients who may be most neglected due to their inability to aptly communicate their pain” (Deschamp, 2007). Studies show that utilizing well-validated developmentally-appropriate pain assessment tools improve compliance with administering therapeutic interventions (Hennes et al., 2005; Swor, McEachin, Sequin, & Grall, 2005; Zempsky & Cravero, 2004). Many tools have been studied; however, there is limited data that concludes which pain assessment tool is best for pediatric trauma patients. These valuable tools include the visual analog scale, color analog scale, Wong-Baker FACES Pain Rating scale, and the verbal rating scale (Figure 1 and 2). The most commonly used tool in pediatrics is the FACES rating scale (Coffman et al., 1997; Garra et al., 2009; Kaplan, Sison, & Platt, (2008); Zempsky & Cravero, 2004; Swor et al., 2005). According to the American Medical Association (2010), other pain scales used include the Poker Chip Scale, the Oucher Scale, and the FLACC Behavioral Pain Assessment. The visual analog scale is set up like a mechanical slide or ruler marked from 0-100 millimeters. It is used for children five years old and up suffering acute, chronic, or recurrent pain and is scored excellent in reliability, validity, and responsiveness. The color analog scale also uses a mechanical slide with variations of pain in the form of colors and widths from white to red to black. This scale is also used for acute, recurrent, and chronic pain in children four years old and up. The color analog scale performs excellent in reliability and validity, and adequate in responsiveness. The Wong-Baker FACES Pain Rating Scale shows the child six different animated pictures of a child’s face, from smiling to crying (figure 1). It is used for children three years old and up. Although the FACES scale is utilized often, it only has proven adequate reliability and validity and poor responsiveness. The verbal rating scale allows the

5 patient to rate their pain from 0-10, 10 being the worst pain. It is now most often used for adults in assessing pain. It is rarely used in pediatric pain assessment (Bailey, Bergeron, Gravel, & Daoust, 2007). The Poker Chip Scale uses four ‘poker chips’ as ‘pieces of hurt’ to allow the child to quantify their pain. The Oucher Scale is similar to the FACES Scale, but it uses photographs of real children’s faces and is available in different ethnic versions. The Oucher Scale uses a numerical scale on the left side from 0-10, with six faces coordinating on the right side for the child to choose (figure 2). The FLACC Behavioral Pain Assessment includes five categories (face, legs, activity, cry, consolability) which are each scored from 0-2 (figure 3). The higher the total score, the more severe the discomfort is for the child. This scale is used for newborns and infants or children who are unable to communicate verbally (American Medical Association, 2010). There is disagreement in which one pain scale should most often be used in the prehospital setting as well as in the emergency department, but the FACES scale and the verbal numeric rating scale are most commonly utilized (Bailey, et al., 2007). Many issues and bias that may hinder care providers from assessing and managing pain in children exist throughout healthcare. In order to change the attitudes of prehospital providers when it comes to pain in children, one study in the American Journal of Nursing shows that a change in behavior must come first. This proves to be significantly important for EMS personnel as they are the front line in pain management and must understand the collaboration that is necessary among all care providers. Educational interventions have been shown to be of statistical significance in the documentation of pain in a timely manner (Lord, 2004). Mendelson and Fallat (2007) imply that the basis for continuing education as the solution for the lack of pain assessment, documentation, and treatment in EMS personnel stems from the inadequate initial training provided. Issues may also arise due to the variability in training and education of EMS

6 staff. Many regions, especially rural areas, use volunteers as prehospital care providers. Inadequate training and skill may then lead to lack of pain assessment, or worse, inappropriate treatment and complications (Mendelson & Fallat, 2007). The appropriate documentation and intervention used before the patient arrives to an emergency department is imperative for many reasons: triaging the patients, further interventions such as analgesics or sedatives, or continued non-pharmacologic methods. Thus, EMS personnel need to be properly and continually trained using evidence-based methods for pain assessment, management, and documentation (Lord, 2004). Simpson et al. (2007) agree that educational programs should not only be implemented, but also emphasize evidence-based pain scales, consistency of documentation, and the emphasis of non-pharmacologic interventions for pain in children.

7 Methods This retrospective analysis of data from LCEMS documentation of pain assessment and intervention for children in prehospital settings has been approved by the Promedica Health System Institutional Review Board (IRB). The electronic run sheets of 278 pediatric patients aged 0-15 years old cared for by LCEMS between the period of May 22, 2007 through December 30, 2009 were collected and analyzed based on various inclusion criteria. LCEMS is an advanced life support (ALS), two-provider transport system serving the entire Lucas County of Northwest Ohio. LCEMS consists of ten life squads – five within Toledo, and five within the suburban areas. The study did not evaluate any other EMS organizations. According to the Lucas County Emergency Medical System official website (2009), there is a protocol that discusses emergencies for patients under the age of 16 years old. The pediatric protocol defines several emergent topics, gives various treatment flow charts for decisionmaking purposes, and then defines the guidelines and special considerations for each unique case. Another protocol discusses the treatment and management of trauma situations, specifies how to assess and evaluate a patient, offers checklists that should be completed on each run, and how to triage patients. While the protocols discuss the appropriate evaluation and management of patients of all ages, including the specific use of pharmacologic intervention, there lacks focus on pain assessment and intervention, as well as on the importance of documentation in the field. The data from 278 LCEMS electronic run sheets were collected using a standardized data collection tool created by professionals within pediatric trauma, emergency medicine, and prehospital emergency services. The data collection tool utilized a coding technique which protected the subjects’ personal health information, and allowed for the informed consent requirement to be waived by the IRB. The data collection was performed completely within the

8 LCEMS offices using a LCEMS secured laptop to review the charts. One graduate student in physician assistant studies was trained by The Toledo Hospital trauma research services to complete the data collection and analysis. The assistance of the information technology team within the central office of LCEMS was essential in pulling specific run sheets based on the population parameters. The inclusion criteria that defined the population parameters included age 0-15 years, children with qualifying traumatic injuries, and transportation to area hospitals by LCEMS. The exclusion criteria included children 15 years or older, fetuses, children who did not have a qualifying traumatic event, children not transported by LCEMS, cancelled runs, incomplete transfer to a local hospital, or injuries that did not occur between the dates of May 22, 2007 and December 29, 2009. The categorical information that was recorded directly from the subject run sheets confirmed the face validity of the data collection tool according to the healthcare and research professionals who collaborated to create it. The data that were collected and coded into a Microsoft Excel spreadsheet included: age, gender, injury zip code, injury year, mechanism of injury, type of injury, number of injuries, scene of injury, EMS arrival time, vital signs (respiration rate and heart rate), documentation of parent intervention in pain control, documentation of pain (yes or no), time pain was documented, pain assessment tool used (yes or no), type(s) of pain assessment tool used, interventions for pain (pharmacologic or non-pharmacologic), type of pain intervention used, time pain intervention implemented, transport location, and transport location arrival time. The mechanism of injury was recorded and coded according to a list: motor vehicle accident, pedestrian struck by vehicles, bicycle accident, falls, burns, downing, sporting accidents, gunshot wound, and a category for other miscellaneous injuries. The injury type was coded according to this list: abrasion, lesion, fracture, head injury, penetrating wound, crush injury,

9 bruise/hematoma, burn, and other miscellaneous injury. The scene of injury was classified and coded into these categories: residence, farm, park, building, recreational site, road/street, school, or other. The transport location was identified as Toledo Children’s Hospital, Mercy Children’s Hospital, or other. The remainder of the data collection was either coded as yes/no, or entered individually by the data collector (i.e. - type of pharmacologic pain intervention). The data gathered were analyzed using simple descriptive statistics of proportions and frequencies. The objective of the study was to evaluate the frequency and types of documented pain assessment and pain intervention within the field of prehospital care for pediatric patients experiencing a trauma. The hypothesis predicts that there is a deficiency in the assessment, documentation, and intervention of pain for pediatric patients in the prehospital setting. Subsequently, a second hypothesis suggests that pain scales designed for children as well as nonpharmacologic pain management for children are both not being utilized adequately.

10 Results The total number of participants meeting this study’s parameters totaled 278 (N = 278). Of those 278 subjects, 55.7% were male (155/278) and 44.3% were female (123/278) (Table 2). The most common injury among both genders was due to a fall at a total percentage of 39.2% (109/278) (Table 1). Considering the percentage of each gender experiencing a fall, 19.4% (52/109) were male and 19.8% (55/109) were female (Table 1, Table 2). The second most common injury among children in this study was a pedestrian struck by motor vehicle accident with 18.7% (52/278). Males dominated this category with 12.9% (36/52) while females made up 5.8% (16/52) of the total victims struck by a motor vehicle. The descending order of occurrence rates continues with motor vehicle accidents at 15.8%, other miscellaneous injury 9.0%, sportrelated injury 6.2%, burn 4.0%, bicycle injury 2.9%, drowning or near-drowning 2.5%, animal bite 0.98%, and gunshot wound 0.72%. Throughout the data collection, inconsistencies among the documentation of age for each subject were found. The actual date of birth was not able to be used for collection purposes due to patient privacy preference by LCEMS. The patients were grouped into age ranges based on years of age from ‘less than 1 year of age’ up to ‘14 years of age,’ separated by one-year increments. The average age could not be accurately calculated due to the ‘less than one year’ age group. However, the largest groups of subjects discovered to be in the ‘less than 1 year of age’ group as well as the ‘1 year of age’ group with 36/278 and 38/278 respectively. The vital signs recorded included respiratory rate and heart rate. The run sheets displayed a discrepancy and even an absence of documentation for a high number of patients. Due to the minor effect the respiration rate and heart rate have on the objective of this study based on current literature, vital signs were eliminated from the data analysis.

11 The documentation of pain assessment resulted in high percentages. Results show that 52.9% (147/278) of all run sheets had documented pain assessment by the EMS team while 47.1% (131/278) did not show any documentation of pain assessment (Table 3). The most common injuries for pain to be assessed and documented included a gunshot injury at 100% (2/2 cases) followed up by sports-related injuries at 82.4% (14/17 cases). Pain was also commonly assessed and documented in bicycle injuries 62.5% (5/8 cases), motor vehicle accidents 61.1% (27/44 cases), and pedestrian struck by a motor vehicle 51.9% (27/52 cases) followed by other miscellaneous injuries, falls, burns, animal bites, and drowning. As for pain intervention, 4.0% (11/278) of run sheets showed documented pharmacologic pain intervention that included either intravenous morphine or intravenous fentanyl with varying dosages, while 96% (267/278) did not have documented pharmacologic pain intervention (Table 4). Some subjects, 1.0% (3/278), did receive both types of intervention, two of the three subjects suffered a fall with a fracture; the other two suffered a fracture from a sports injury. In these cases, the fractured body part was splinted and either fentanyl or morphine was administered. The most common injury with positive documentation of pain evaluation to receive pharmacologic intervention was a sports-related injury at 35.7% (5/17; Table 4). Nonpharmacologic intervention for pain was also assessed. Of the 278 run sheets, only 6.5% (18/278) had documented non-pharmacologic intervention while 93.5% (260/278) did not show any documentation (Table 5). Non-pharmacologic interventions included application of ice, dressing/bandage, splinting/traction, distraction/diversion, or holding/swaddling child (Table 5). The most common form of non-pharmacologic pain intervention included application of ice to the injury at 2.5% (7/278). An injury resulting from an animal bite was the most common injury with documentation for pain to receive non-pharmacologic intervention in the form of a wound

12 dressing at 100% (2/2; Table 5). Next most common non-pharmacologic intervention to injuries with positive documentation of pain included drowning 50% (1/2), gunshot injury 50% (1/2), a sports-related injury 21.4% (3/14), and then a bicycle injury 20% (1/5; Table 5).

13 Discussion The current study faced various limitations discovered throughout the data collection process and analysis, most of which were due to documentation discrepancies. This is true for all types of medical record keeping. The information obtained from a chart or a run sheet is both subjective and objective, regardless of the specialty of healthcare (primary care versus trauma). In the current study, the questions asked and statistics analyzed were aimed at answers such as mechanism of injury, types of injury obtained, pain rating, vital signs, parental involvement of care, and use of pharmacologic and non-pharmacologic intervention. However, in medical record keeping, the recorder of the information can tweak the information subjectively. Many run sheets lacked important information such as a narrative explaining the chief complaint, history of present injury, and subsequent actions. It is unknown whether or not the information was not asked, not documented, or irrelevant. The pain scale utilized for pediatric patients is a prime example. Only 52.9% (147/278) of run sheets showed assessment of pain. If no pain rating was recorded, it could mean the patient was not experiencing pain, the question was not asked, or the rating was not recorded. In this retrospective study, the pain rating documented was only recorded in the form of the numeric pain scale. It was unclear whether or not the EMS provider utilized the FACES pain scale option within their electronic medical record keeping tool. The accuracy and reliability of the data assessment tool used is only as consistent as the records of the EMS providers (Baxt et al., 2004). It is also unclear if the patients experiencing no pain at all were assessed, or if the documenter chose not to record the pain quantitatively as a zero out of ten. If this is the case, the lack of pain assessment and documentation could be attributed to zero pain experienced or to lack of documentation. According to LCEMS, this

14 factor is not included in the pediatric pain assessment protocol and is user dependent, varying among each independent EMT. In reference to this current study, the lack of variety of pain scales used in the field promotes a universal problem in the prehospital evaluation of pain in children. Although the FACES scale is an option within the computer system used in the field, the run sheets utilized did not specify when the FACES scale was used to obtain the scaled number (out of ten) versus the numeric pain scale. All documented pain assessment was in the form of the numeric pain scale. The importance of consistency displayed by LCEMS using the numeric pain scale for every run sheet is supported by the most recent literature, but the lack of documenting whether or not the FACES scale was used to obtain a number from one to ten is poor medical practice. For the large variety of cognitive ability between different ages of children, one type of pain scale cannot be used universally (Baxt et al., 2004). For future studies, an in depth analysis studying the use of pain scales in the prehospital setting may be of benefit to EMS organizations. However, for the purpose of this study, the type of pain scale used for assessment is not a significant finding, only whether or not pain was assessed at all. The resource of the history given to the EMT is also an unknown variable. Many situations involving a trauma force any witness involved to elaborate on the event. This may include a parent or guardian, a relative, a friend of the child, or many times, a stranger to the patient. Subsequently, many problems can arise from inadequate information. Also, the assessment of the severity of pain should be, but is not always based upon the development and cognitive ability of the child, as well as the severity of the injury (Hauer et al., 2011). Many times, a parent or guardian will speak for the child when it comes to pain. A child with a traumatic brain injury, for example, may not be able to accurately assess their current pain. The

15 paramedic then may record the parents’ information and evaluation as coming directly from the child. Only few run sheets within the study described a narrative in detail, including the resource of the assessment of pain. Therefore, the subjective data taken from a child or a witness of the event should be interpreted carefully. Continuing education to EMS providers may benefit by addressing this issue, as well as the following discussion on pain intervention (Coffman et al., 1997). The current research study shows a huge lack in the use of non-pharmacologic pain intervention. Only 6.5% (18/278) run sheets displayed documentation of some form of nonpharmacologic attempt at pain relief. Only 4.0% (11/278) of the patients received pharmacologic intervention. Because there is such hesitancy of the use of pharmacologic pain relievers such as morphine and fentanyl, non-pharmacologic techniques have been studied and proven to be just as effective for children, especially in traumatic situations. However, as frontline care in traumatic events, EMS providers must be adequately trained in evidence-based implementation of non-pharmacologic as well as pharmacologic pain control (Lord, 2004). Several non-pharmacologic interventions have been proven effective in controlling pain in pediatric patients according to many past studies. Non-pharmacological interventions include distraction, music, pacifier use, holding, rocking, touch, repositioning, quiet environment, ice application, and massage (Coffman et al., 1997). In another study, some non-pharmacological interventions included distraction with a bubble blower or pinwheel, light wands, and imagery projectors (Zempsky & Cravero, 2004). Several other studies documented that the presence of the child’s parents not only yielded better pain assessment, but also served as a nonpharmacological aid in distracting children and thus helping to alleviate their pain (Coffman et al., 1997; Baxt, Kassam-Adams, Nance, Vivarelli-O’neil, & Winston, 2004; Manworren &

16 Hynan, 2003; Mendelson & Fallat, 2007; Zempskey & Cravero, 2004). It can be concluded from literary research that professional training increases knowledge about and inclination towards the use of pediatric pain assessment and non-pharmacological interventions for pain among prehospital providers.

17 Conclusion The purpose of this study was to determine a baseline of prehospital provider pain assessment, documentation, and intervention of pediatric patients experiencing a traumatic injury. Collectively, the investigators of this study have concluded that there is a lack of knowledge about the importance of pediatric pain assessment, documentation, and management within the prehospital setting. Future re-evaluation on this subject may include a variety of additions. One may be to implement further continuing medical education programs specific to the topic of pediatric pain. Within an education program, the established pain scales that can be used based on a child’s age and ability, the reason and importance behind documenting sufficient information from the EMS evaluation, as well as managing a child’s pain both nonpharmacologically and pharmacologically should all be emphasized and practiced. Also, the protocols within emergency medical service organizations should be reviewed frequently for any further updates and additions on the topic of pediatric pain control.

18 References American Medical Association. (2010). Module 6 pain management: Pediatric pain management. Retrieved from: http://www.amacmeonline.com/pain_mgmt/module06/03pain/03_01.htm. Bailey, B., Bergeron, S., Gravel, J., & Daoust, R. (2007). Comparison of four pain scales in children with acute abdominal pain in a pediatric emergency department. American College of Emergency Physicians, 50(4), 379-383e1-2. doi:10.1016/j.annemergmed.2007.04.021 Baxt, C., Kassam-Adams, N., Nance, M. L., Vivarelli-O’neil, C., & Winston, F. K. (2004). Assessment of pain after injury in the pediatric patient: Child and parent perceptions. Journal of Pediatric Surgery, 39(6), 979-983. Baxter, A. L., & Cohen L. L. (2009). Pain management. In G. R. Strange, R. Schafermeyer, W. Ahrens, & R. A. Wiebe (Eds.), Pediatric emergency medicine (3rd ed.). New York: McGraw-Hill. Coffman, S., Alvarez, Y., Pyngolil, M., Petit, R., Hall, C., & Smyth, M. (1997). Nursing assessment and management of pain in critically ill children. Heart & Lung 26 (3), 221228. Deschamp, C. (2007, June 26). Prehospital management of pediatric pain. Journal of Emergency Medical Services. Retrieved from: http://www.jems.com/article/specialpatients/prehospital-management-pediatr. Garra, G., Singer, A. J., Taira, B. R., Chohan, J., Cardoz, H., Chisena, E., & Thode, H. C. (2010). Validation of the Wong-Baker FACES Pain Rating Scale in pediatric

19 emergency department patients. Academic Emergency Medicine, 17, 50-54. doi:10.1111/j.1553-2712.2009.00620.x. Hauer, J., Jones, B. L., & Wolfe, J. (2011). Evaluation and management of pain in children. Available from: http://www.uptodate.com/ Hennes, H., Kim, M.K., & Pirrallo, R.G. (2005). Prehospital pain management: A comparison of providers’ perceptions and practices. Prehospital Emergency Care, 9(1), 32-39. doi:10.1080/10903120590891705 Izsak, E., Moore, J. L., Stringfellow, K., Oswanski, M. F., Lindstrom, D. A., & Stombaugh, H. A. (2008). Prehospital pain assessment in pediatric trauma. Prehospital Emergency Care, 12(2), 182-186. doi:10.1080/10903120801907471 Kaplan, C. P., Sison, C., & Platt, S. L. (2008). Does a pain scale improve pain assessment in the pediatric emergency department? Pediatric Emergency Care, 9, 605-208. doi:10.1097/PEC.0b013e3181850c1c Lord, B. (2004). The paramedic’s role in pain management. American Journal of Nursing. 104(11), 50-53. Lucas County Emergency Medical Services. (2011). Tab 1100. Pediatric protocols. Retrieved from: http://www.co.lucas.oh.us/index.aspx?nid=420 Manworren, C. B. & Hynan, L. S. (2003). Clinical validation of FLACC: Preverbal patient pain scale. Pediatric Nursing, 39(2), 140-146. Mendelson K. G., & Fallat, M. E. (2007). Pediatric injuries: Prevention to resolution. Surgical Clinics of North America, 87, 207-228. doi:10.1016/j.suc.2006.09.016 McLean, S. A., Maio, R. F., & Domeier, R. M. (2002). Epidemiology of pain in prehospital setting. Prehospital Emergency Care, 6(4), 402-405.

20 Strange, G. R., Ahrens, W. R., Schafermeyer, R. W., & Wiebe, R. A. (Eds.). (2009). Pediatric emergency medicine (3rd ed.). New York: McGraw-Hill. Simpson, D., Szewczuga, D., Hennes, H., Pirrallo, R., & Kim, M. (2007, October 5) Prehospital pain management for children: A focus group report of EMS providers. Retrieved from: http://www.allacademic.com/meta/p64905_index.html Swor, R., McEachin, C. M., Sequin, D., & Grall, K. H. (2005). Prehospital pain management in children suffering traumatic injury. Prehospial Emergency Care, 9(1), 40-43. doi:10.1080/10903120590891930 Zempsky, W.T., & Cravero, J.P.; American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. (2004). Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics, 114, 1348-1356. doi:10.1542/peds.2004-1752

 

21 Tables TABLE 1 Age