Pain Intensity and Risk of Bone Fracture in Children With Minor Extremity Injuries.

OBJECTIVES: Injuries are one of the most common causes of pediatric emergency department (ED) visit. The aim of this study was to investigate the relationship between the intensity of pain at the ED visit of children presenting with an extremity injury and the risk of fracture. METHODS: We conducted a retrospective study, considering all patients presenting to the ED of a children's hospital in Italy, with an accidental extremity injury, between May and December 2015. We selected all children aged 8 to 17 years who underwent an x-ray. Children with major, multiple, or nonextremity injuries were excluded. Age, sex, spontaneous and palpation pain, local swelling, time between injury, and medical evaluation were recorded. Sensibility and specificity of spontaneous and palpation pain in detecting a fracture were calculated. RESULTS: We reviewed 994 medical records; of these, 344 (34.6%) reported a fracture. Children's median age was 12 years (interquartile range [IQR], 10-14). Median spontaneous pain at the ED visit was not significantly different between children with and without a fracture: 4.0 (1.0-6.0) and 5 (1.0-6.0), respectively (P = 0.129). Children with mild palpation pain and children without an increase of pain of at least 2 points between spontaneous and palpation pain were fractured in 3.2% and 0.97% of cases, respectively. CONCLUSIONS: In this series, pain intensity in children with a minor extremity injury was not a good marker of fracture. Nevertheless, children with mild palpation pain or with a mild increase of pain between spontaneous and palpation pain had a low risk of fracture.

Narrative review shows that the short-term use of ketorolac is safe and effective in the management of moderate-to-severe pain in children.

In June 2013, the European Medicine Agency recommended limiting codeine use in paediatric patients, creating a void in managing moderate pain. We reviewed the literature published in English (1985-June 2017) on the pharmacokinetic, pharmacodynamic and safety profile of ketorolac, a possible substitute for codeine and opioids, for treating moderate-to-severe pain. We found that gastrointestinal side effects were mainly reported with prolonged use, significant bleeding was reported in adenotonsillectomy, and adverse renal effects appeared to be limited to patients with specific coexisting risk factors. CONCLUSION: The short-term use of ketorolac appears to be safe for children in many situations.

An adolescent with acute abdominal pain and bowel wall thickening.

: A 15-year-old girl was admitted with acute crampy abdominal pain and repeated vomiting over the preceding 2 hours; no fever, diarrhoea or abdominal trauma was reported. She had started oestrogen-progestin contraception 3 months ago. She had sought medical advice twice in the previous weeks for self-limiting episodes of right hand swelling, without urticaria. On examination, she was unwell and in pain, with severe tenderness in the right lower quadrant, without guarding or rebound tenderness. Bowel sounds were diminished. Blood tests were unremarkable. Two hours after admission, an abdominal ultrasound scanning showed an impressive wall thickening (>1 cm) of the terminal ileum, caecum and ascending colon (figure 1). Abundant free intraperitoneal fluids in the pelvis and in the hepatorenal recess were present.edpract;103/1/22/EDPRACT2016311823F1F1EDPRACT2016311823F1Figure 1Marked caecal wall thickening evidenced at the ultrasound scanning. QUESTIONS: Which of the following is the most likely diagnosis in this patient? Ileocolic intussusceptionGastrointestinal manifestation of Henoch-Schönlein purpuraAbdominal attack of hereditary angioedema (HAE)Acute pancreatitisWhich of the following blood tests may help to confirm the diagnosis? Erythrocyte sedimentation rateC4Serum amylase: 36 IU/LC1-inhibitorHow should this patient be evaluated and treated?Answers are on page ▪▪▪.

Current concepts in management of pain in children in the emergency department.

Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

Risk of hospitalisation after early-revisit in the emergency department.

AIM: Early-revisits are frequent in the paediatric emergency department (ED) setting, but few data are available about early-revisited patients. The aim of this study was to investigate the hospitalisation rate of a population of early-revisited patients and to detect if an early-revisited patient was at risk of a more severe disease. METHODS: Between June 2014 and January 2015, we conducted a retrospective cohort study, considering all patients presented to the ED of a tertiary level children's hospital in Italy. We selected all patients who were revisited within 72 h from the initial visit (study cohort), while all other patients accessed in the same period were considered the control cohort. The two cohorts were compared for age, gender, triage category, hospitalisation rate, diagnosis at admission and hospital length of stay. RESULTS: In the study period, we reviewed 10 750 visits, of which 430 (4%) were unplanned revisits for the same chief complaint within 72 h from the initial visit. Hospitalisation rate of early-revisited patients was significantly higher compared to control patients (8.4 vs. 2.9%). Hospitalisation rate increases in parallel with the number of revisits, but in many cases, it was not directly related to a worst triage category, neither to a longer hospital length of stay. CONCLUSION: Early revisited patients in the ED had a significantly higher risk of hospitalisation, but this risk was only partially related to their clinical conditions.

Tramadol can selectively manage moderate pain in children following European advice limiting codeine use.

UNLABELLED: The European Medicine Agency recommendations limiting codeine use in children have created a void in managing moderate pain. We review the evidence on the pharmacokinetic, pharmacodynamic and safety profile of tramadol, a possible substitute for codeine. CONCLUSION: Tramadol appears to be safe in both paediatric inpatients and outpatients. It may be appropriate to limit the current use of tramadol to monitored settings in children with risk factors for respiratory depression, subject to further safety evidence.

Carbamazepine hypersensitivity syndrome triggered by a human herpes virus reactivation in a genetically predisposed patient.

A case of severe hypersensitivity syndrome, triggered by carbamazepine in the presence of a concomitant active human herpes virus (HHV) 6 and 7 infection is described. To further understand the molecular mechanism of this adverse reaction, analyses of the genetic variants of human leukocyte antigen (HLA) and of the epoxide hydrolase gene (EPHX1), previously associated with carbamazepine hypersensitivity, were performed. A lymphocyte transformation test (LTT) was conducted in order to detect drug-specific lymphocytes. In the hypersensitive patient, 2 genetic factors previously associated with intolerance to carbamazepine were detected: the allele HLA-A*3101 and homozygosity for the variant allele of SNP rs1051740 in EPHX1. Drug-specific lymphocytes could be detected by LTT when the HHV was active (positive PCR for viral DNA and increased anti-HHV 6 IgG titer), but not when it was no longer active. In conclusion, we document a case of severe carbamazepine hypersensitivity triggered by viral reactivation in a patient presenting the interaction of 2 unfavorable genetic factors.