Children with Limb Trauma Remain Suboptimally Treated for Pain in Emergency Departments

BALTIMORE, Md.—Despite receiving ibuprofen and codeine, children presenting to an emergency department (ED) with limb trauma had moderately high pain scores after 120 minutes. These results suggest that to reach a clinically significant decrease in pain, an NSAID should be combined with an opioid stronger than codeine, researchers reported at the American Pain Society's 29th Annual Scientific Meeting.

Sylvie LeMay, PhD, of the University of Montreal and CHU Sainte-Justine, Montreal, Quebec, Canada, and colleagues pointed to studies that show that children presenting to EDs with a fracture or a severe sprain receive fewer analgesics (53%) than adults (73%) for the same diagnosis as well as fewer opioids for pain (26% compared with 46% for adults).

The investigators evaluated the efficacy of an NSAID (ibuprofen) and opioid (codeine) combination on pain relief in children aged 6 to 17 years, noting that few—if any—trials have studied such a combination. Children presenting to the ED with limb trauma were randomized at triage to receive either ibuprofen plus codeine (n=42) or ibuprofen only (n=41). The primary outcome was a minimal difference of 20 mm (2 scores) on the Visual Analogue Scale (VAS) at 60, 90, and 120 minutes compared to pain intensity at triage.

Patients were not expected to undergo reduction based on triage assessment; had an angulation of <30 degrees; incurred the trauma within the previous 72 hours; and had a pain score >30 mm on the VAS. At baseline, patients in the experimental group had their pain measured and then received a syrup of codeine and chewable tablets of ibuprofen. A splint was installed and they were returned to the ED waiting room for examination by a physician and to have an x-ray taken. The control group followed the same procedure; however, they received a syrup of a placebo solution with chewable tablets of ibuprofen.

Mean age of the children was 11.2 ± 3.6 years in the experimental group and 10.9 ± 2.4 years in the control group; 54.3% of all children were male. The most prevalent injury was fracture, which occurred in 47%. One patient in the experimental group complained of nausea; no other side effects were reported at any time points.

No significant differences were found between groups at each time point; at 120 minutes, the mean pain intensity score was 3.5 ± 2.5 in the codeine/ibuprofen group and 3.8 ± 2.4 in the placebo group (P=0.60). However, significant differences were observed among each group between triage and each time period.

The investigators noted that the absence of differences between the groups might be related more to splinting the limb than to use of medication. In addition, while there was no additive value with use of the combined analgesics, few side effects were encountered.