Nerve blocks for initial pain management of femoral fractures in children.

BACKGROUND: Children and adolescents with femoral fractures are almost always admitted to hospital. They invariably start their hospital experience in the Emergency Department, often requiring transfer to a specialist children's hospital. They require analgesia or anaesthesia so that radiographs can be obtained and for management of their fractures. The initial care process involves from two to six transfers from stretcher to stretcher/imaging/operating-suite table or hospital bed within the first few hours, so prompt pain relief is essential. Systemic analgesia can be provided orally or parenterally. Alternatively, a nerve block may be used where local anaesthetic is injected around a nerve to block sensation or freeze the involved area. OBJECTIVES: To assess the effects (benefits and harms) of femoral nerve block (FNB) or fascia iliaca compartment block (FICB) for initial pain management of children with fractures of the femur (thigh bone) in the pre-hospital or in-hospital emergency setting, with or without systemic analgesia. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (11 January 2013), the Cochrane Central Register of Controlled Trials (2012 Issue 12), MEDLINE (1946 to January Week 1 2013), EMBASE (1980 to 2013 Week 01), Google Scholar (31 January 2013) and trial registries (31 January 2013). We handsearched recent issues of specialist journals and references of relevant articles. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials assessing the effects of FNB or FICB for initial pain management compared with systemic opiates in children (aged under 18 years) with fractures of the femur receiving pre-hospital or in hospital emergency care. Primary outcomes included failure of analgesia at 30 minutes, pain levels during procedures and transfers (e.g. to a stretcher or hospital ward) for up to eight hours, and adverse effects. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data using a pre-piloted form. Two authors independently assessed the risk of bias for the included study and assessed quality of the evidence for each outcome using the GRADE approach; i.e. as very low, low, moderate or high. Meta-analysis of results was not possible as we found only one trial that could be included in the review. MAIN RESULTS: We included one randomised trial of 55 children aged between 16 months to 15 years. It compared anatomically-guided FICB versus systemic analgesia with intravenous morphine sulphate. The small sample size and the high risk of bias relating to lack of blinding resulted in a low quality rating for all outcomes.Overall, the trial provided low quality evidence for better pain management in the FICB group. Fewer children in the FICB group had analgesia failure at 30 minutes than in the morphine group (2/26 (8%) versus 8/28 (29%); risk ratio (RR) 0.33, 95% confidence interval (CI) 0.09 to 1.20; P value 0.09). The trial did not report on pain during procedures or transfers, or application of analgesia. The trial provided low quality evidence that FICB has a better safety profile than morphine, with only four (15%) reports of redness and pain at the injection site, and no reports of the type of adverse effects of systematic analgesia that occurred in the morphine group, such as respiratory depression (six cases (21%)) and vomiting (four cases (14%)). No long-term adverse events were reported for either intervention. Clinically significant pain relief was achieved in both groups at five minutes; with limited evidence of greater initial pain relief in the FICB group. Based on an inspection of graphically-presented data, at least 46% (12/26) of children in the FICB group had no supplementary medication (mainly analgesia) for the six hours of the study, while only 5% (1 or 2/28) of children in the intravenous morphine group went without additional analgesia. There was insufficient evidence to determine whether child or parental satisfaction with the method of analgesia favoured either method. Resource use was not measured. AUTHORS' CONCLUSIONS: Low quality evidence from one small trial suggests that FICB provides better and longer lasting pain relief with fewer adverse events than intravenous opioids for femur fractures in children. Well conducted and reported randomised trials that compare nerve blocks (both FNB and FICB) with systemic analgesia and that use validated pain scores are needed.

Postnatal depression in mothers bringing infants to the emergency department.

OBJECTIVE: To determine the prevalence of postnatal depression (PND) in mothers of young infants presenting to the emergency department (ED). DESIGN, SETTING AND PARTICIPANTS: Prospective observational study of the prevalence of PND in mothers of infants aged 14 days to 6 months presenting with non-time-critical conditions to the ED of a large tertiary paediatric hospital. MAIN OUTCOME MEASURES: We assessed PND by applying a self-administered validated screening tool, the Edinburgh Postnatal Depression Scale (EPDS). Mothers of patients were approached before clinician consultation when a social worker was available on site. EPDS scores of 13 and above were considered 'positive'. Univariate analysis was used to determine associations with demographic, maternal and child factors. RESULTS: 236 mothers were approached; 200 consented to participate in the study. Thirty-two mothers screened positively, with a prevalence rate of 16% (95% CI 11.2% to 21.8%). A positive screen was most strongly associated with history of depression (relative risk (RR) 4.8, 95% CI 2.3 to 10.1). Other associations were with single-parent status (RR 2.5, 95% CI 1.1 to 5.4), Indigenous status (4.4, 95% CI 1.8 to 10.4) and 'crying baby' as the presenting problem (RR 2.9, 95% CI 1.4 to 6.2). Fifty-three per cent of mothers had not completed a PND screen before coming to the ED. CONCLUSIONS: Mothers of young infants coming to the ED regardless of infant's presenting complaint have a high prevalence of PND determined using the EPDS. Many mothers were not screened for PND before coming to the ED. Clinical staff need to be aware of the condition, incorporate appropriate questioning into the consultation, and refer mothers to support services if necessary.

The increasing problem of motorcycle injuries in children and adolescents.

OBJECTIVE: To quantify an anecdotally apparent increase in motorcycle-related injuries in children and adolescents across Victoria. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of paediatric motorcycle injuries (1 July 2000 - 30 June 2004) from a statewide emergency department (ED) database (Victorian Emergency Minimum Dataset [VEMD]) and the Trauma Registry database at the Royal Children's Hospital (RCH), Melbourne. MAIN OUTCOME MEASURES: Trends in paediatric motorcycle-related injuries over time; patient demographics, circumstances of accidents (on or off road), and injury characteristics, including severity markers. RESULTS: The VEMD recorded 3163 patients aged < or = 16 years presenting to EDs with motorcycle injuries during the study period; population-based rates of these injuries increased by an average of 9.6% per year (95% CI, 6.2%-13.1%; P < 0.005). In the same period, there was a total of 167 motorcycle-related admissions to the RCH, increasing annually in line with statewide ED presentations. About a quarter of paediatric motorcycle accidents occurred in children aged under 10 years (VEMD, 22%; RCH, 27%) and most occurred off road (VEMD,89%; RCH, 71%). At the RCH, median length of stay was 3 days (interquartile range [IQR], 1-7 days) and the median Injury Severity Score was 9 (IQR, 4-10); 41% of patients required an operation, 13% were admitted to an intensive care unit, and two died. CONCLUSION: In Victoria, the incidence of motorcycle-related injuries is increasing in children and adolescents. Most of these injuries occur off road, outside of any legislative framework. There is an urgent need for coordinated legislative changes and educational efforts to decrease motorcycle injuries in children.