Pediatric emergency medicine trisk 3420 3420

Rapid assessment and treatment of pain both in the ED and after discharge are
key components of the emergency care of musculoskeletal trauma. Increasingly,
triage protocols include the administration of appropriate oral analgesics prior to
physician care. For significantly painful injuries, clinicians should consider
intranasal fentanyl, which has the advantage of a relatively fast onset of action
(<5 minutes) without requiring an IV. Following these initial efforts at pain
control, vascular access can be obtained for IV narcotics if clinically indicated.
After discharge from the ED, children experience the most fracture-related pain
in the first 3 days. Ibuprofen and acetaminophen are recommended for first-line
pain control at home. For some children, a prescription for a short duration (e.g.,
2 to 3 days) of narcotics may be considered to treat breakthrough pain after
administration of ibuprofen and acetaminophen. This may be considered for
children requiring narcotics for pain control while in the ED and those children
discharged overnight (between 10 PM and 8 AM ), as they are at increased risk of
having more pain. These children may benefit from having a prescription for oral
narcotics to be taken at home for pain. Acetaminophen with codeine is no longer
recommended due to the variable metabolism of codeine in different populations,
leading to either ineffective pain control or the risk of respiratory compromise. It
is important to provide anticipatory guidance to patients and caregivers that some
pain is to be expected for 2 to 3 days after a fracture and to recommend treatment
with over-the-counter analgesics and nonpharmacologic distraction techniques.
This may minimize the use of narcotics for pain control after discharge.

Goals of Treatment
A systematic approach to the evaluation and management of pediatric
musculoskeletal injuries is important in order to avoid overlooked injuries and
prevent potential complications. The initial goals of treatment in the ED are to
provide pain control, evaluate the injured extremity for any neurovascular
compromise, and immobilize the injured area. Next, the specific injury must be
identified with physical examination and radiologic imaging. The injured
extremity should be immobilized to enhance comfort and prevent further trauma

until definitive orthopedic care can be obtained. Adjunctive interventions such as
elevating the injured extremity and applying a cold pack can help mitigate
swelling.

Clinical Considerations
Clinical Recognition