Annual Meeting Reviews
Pediatric Trauma
By Elizabeth M. Ross, MD
Assistant Professor Anesthesiology and Pediatrics
UNC-Children’s Hospital
Chapel Hill, North Carolina
This year’s trauma component of the spring SPPM meeting displayed an impressive array of speakers. From implementing regional anesthesia at the first encounter, to creating a calming, supportive environment, and transitioning patients’ pain management plan for active rehabilitation, this series had you covered. A special bonus this year is that if you missed it live, lectures are still available until next spring for you to view at your convenience. Until then, here are some highlights from the trauma front.
Christina Benki, PhD, a clinical psychologist from UCSF Benioff Children’s Hospital spoke on the relationship between pediatric traumatic stress and chronic pain. We learned that while about 50% of all children experience an adverse childhood event, less than 0.5% will develop PTSD. Yet, 32% of pediatric patients experiencing chronic pain concurrently suffer from PTSD. Given the high rate of co-occurrence, both ailments must be treated simultaneously, ideally utilizing a mutual maintenance model.
Treating children affected by trauma can be exceedingly challenging; healthcare teams must treat the family unit, as a child’s sense of safety depends on the safety of their caregivers. Dr. Benki recommends approaching patients who have experienced a trauma using Trauma Informed Care (TIC) interventions. TIC is a systems level care that involves screening, collaboration of multidisciplinary teams, and patient understanding. TIC decreases the stress of procedures and thus alleviates the pain experience. In TIC, the healthcare team supports the patient and caregiver in their varied psychosocial needs to guide the patient to return to realistic, age-appropriate activities.
Melissa Masaracchia, MD, a pediatric anesthesiologist from Children’s Hospital Colorado refreshed us on considerations for regional anesthesia in the pediatric patient with extremity trauma. The overarching worry with extremity trauma is acute compartment syndrome (ACS). While any analgesic medication can theoretically mask the pain (and delay detection) of ACS, many surgeons and anesthesiologists fear regional blockade more. In attempting to grow your regional service, select appropriate injuries and avoid fractures of the lower leg and forearm where ACS is most common.
Additionally, it may be helpful to share Mar et al’s study which showed that regional anesthesia facilitated the detection of ACS when break-through pain occurred in the presence of previously well-controlled pain.1 Further, the traditional 5-Ps that typically alert clinicians to ACS in adults are not as efficacious in diagnosing children. Instead, look for the 3-As: increasing agitation, anxiety, and analgesic requirement. In addition, to decrease the chance of masking ACS, use lower concentrations of local anesthetic and in lower volumes, be judicious or eliminate the use of additives, and practice increased vigilance with more frequent neuro-checks and follow-ups, something your APS team could certainly assist with performing.
Chi-Ho Ban Tsui, MD, a regional anesthesiologist from Stanford University, gave us clinical pearls for truncal regional anesthesia in pediatric patients. While many barriers exist to utilizing truncal anesthesia in this patient population, they can be overcome. Competition with resuscitative measures can be obviated by performing the blocks after surgical intervention. The patient will still be able to reap the post-operative pain management benefits. This will also allow you to better assess coagulation status to determine the safest regional modality, be it central neuraxial or fascial plane. All together these measures will increase the number of patients benefiting from the treatment, and inexperience will fade away.
Dr. Ban Tsui further explained that we must weigh risks and benefits of using a central neuraxial technique to interfascial block. Often the superior hemodynamic stability and decreased risk of coagulation or positioning issues of interfascial blocks outweighs the possible inferior pain control. Truncal blocks run on a spectrum from spinal space to midline rectus sheath. The key to a successful truncal block is to find the location along the nerve that offers the safest site of block with the best possible pain control. Further, the success of interfascial blocks relies on volume, consequently, intermittent boluses often provide superior pain control to continuous infusions when continued postoperatively.
Finally, rectus sheath blocks are most safely performed above the level of the umbilicus where the fascia is thicker. Angela Garcia, MD, a physical medicine and rehabilitation physician from UPMC Children's Hospital of Pittsburgh, spoke on pain management on the inpatient rehabilitation unit for the trauma patient. Success is all about getting the patient to participate, and pediatric pain physicians play an important role in creating a pain management plan that allows for increased participation in treatment and consequent patient improvement. Many barriers exist to transition a patient from an immobile post-surgical state to an active, functioning child, but they are not insurmountable. Dr. Garcia reminded us that as we treat these patients, we need to think long term and be deliberate about the medications we choose.
For example, convert medications from intravenous to long-acting PO (such as methadone) or cutaneous when at all possible. Freeing the patient from their IV lines and tubes helps ensure productive, safe rehabilitation. Pain physicians also need to keep in mind side effects such as drowsiness, as decreased alertness hinders the participation needed to succeed in physical rehabilitation. Lastly, continued use of cognitive behavioral therapies during inpatient rehabilitation is paramount to achieve success.
The speakers concluded with an excellent Q&A session that helped answer some questions on how to implement these services into individual practices. With the virtual format, all submitted questions were answered online, so be sure to visit those as well. Overall, SPPM was able to present another relevant session to help us all take the best possible care of patients.
Reference
- GJ Mar, MJ Barrington, BR McGuirk. Acute Compartment Syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. British Journal of Aneasthesia.I 102(1): 3-11 (2009).
