Welcome to this month's webinar on Pain Management of a Pediatric Orthopedic Patient. We have Dr. Brian Scannell from here in our hometown, Charlotte, North Carolina doing the presentation today. He specializes in pediatric orthopedics. He was raised here in Charlotte, North Carolina. He's going to talk about pain management of a pediatric orthopedic patient, and he'll talk about pain management of a pediatric orthopedic patient. He received his medical degree from the University of North Carolina at Chapel Hill. He completed his residency, which included participation in a year-long research fellowship at Carolina Medical Center. In 2013, he journeyed on to Grady Children's Hospital in San Diego for his fellowship. He currently serves as the Associate Program Director for the Orthopedic Residency Program, the medical student directory for the orthopedics. He has a wide range of pediatric clinical interests, including trauma, spine, hip dislocations, and lower extremity forming. Welcome, Dr. Scanelli. Next. While you're on the conference line for sound, please go ahead and call in the toll-free number and insert your access code as well as your PIN number. Keep in mind that there is an additional charge if you have two or three hospitals or people from your hospital calling in on different lines. Check your e-mails for handouts. They're also available via GoToWebinar. All attendees are muted by default. And at the very end, if you'd like to ask a question, either raise your hand and we will, you can verbally ask your question or you can type it in in the information area. For evaluation, please follow the link to SurveyMonkey. You will also be receiving an e-mail from PCAA following the webinar with the link included. In order to receive your CMEs or CEs, you must complete the evaluation as well as provide your contact information. There are no disclosures to the presentation, but a lot of the slides were related to opiates and some of the pain management are courtesy of his co-worker, Dr. Joseph Hazoo. And at this point, I'd like to turn the program over to Dr. Scanelli. Welcome. Thank you, everybody, and good afternoon. Again, Dr. Hsu is one of my adult trauma colleagues, and he has a huge passion in regards to pain management for trauma patients, particularly on the adult side. And he has been very instrumental in helping me kind of put together this talk today. Certainly try to put much more of a pediatric slant on it today. We'll go through a few things in regards to compartment syndrome as well, which I think is important for anybody that's taking care of trauma patients to be able to recognize, and it's clearly related to pain as well. At the end, if there's some time, I'll give just kind of a brief update on management of open fractures. There has been some changing literature in the last number of years in regards to orthopedics and open fractures, and if we have some time, we'll go through a little bit of that at the end. So the pediatric polytrauma patient, although not nearly as common as the adult polytrauma patient, is definitely common. One in four children presenting to hospitals have traumatic injuries, and trauma, of course, is still leading to death of children under the age of 18. About 63% of pediatric polytrauma patients will present initially with extremity fractures as well. And rarely are these orthopedic or musculoskeletal injuries the cause of mortality, but they often can result in longer-term morbidity. This is looking at kind of the epidemiology of fractures in children, and this includes both isolated injuries as well as polytrauma patients. And what you see is certainly a bigger spike as children get older, reach adolescence, and certainly a much larger spike in the male adolescent as compared to the female adolescent. There are a lot of different orthopedic injuries. I'm not going to kind of cover all of these individually and the care of all these, but certainly what we do and take care of involving polytrauma patients involves spine trauma, certainly compartment syndrome, open fractures, your minor as well as severe extremity trauma in patients with both vascular and neurologic injuries. Unfortunately, in the south here, we see a lot of lawnmower injuries, which result in amputations frequently in young children. And then, unfortunately as well, we see a fair amount of non-accidental trauma or child abuse. I'm on call today and unfortunately just got called about an hour with an additional case of NAT. So these are all very, very common things that are managed from a multidisciplinary standpoint. A lot of these patients have multiple injuries that are non-orthopedic, and certainly we try and I try to teach my residents to have a non-orthocentric approach and really making sure that they know everything else that's going on with these patients, including those head injuries, traumatic brain injuries, spinal cord injury, thoracic injuries, including rib fractures, pneumothorax, as well as abdominal injuries. I think it is important for trauma surgeons as well as orthopedic surgeons to recognize the association of spine fractures as well as bowel injuries. Most of these are seatbelt type injuries with a flexion and distraction type injury to both the bowel as well as to the spine and spinal cord. Here at Carolinas Healthcare System, we are now a level one pediatric trauma center, but we have been a level one adult for quite some time. We take care of a lot of injuries, and management of these patients can be fairly complex from the standpoint of multidisciplinary approach as well as from a pain management perspective. This is a 16-year-old that was in the hospital for nearly two months, and eventually went on to, fortunately, live and salvage, but had a very severe upper extremity injury. And unfortunately, we also see a lot of cases, as I said earlier, of lawnmower injuries. This is a five-year-old male who was riding on a lawnmower with his grandfather and fell off. And so, some injuries, although they may be isolated like these, also may have kind of multiple injuries like this, which is an unfortunate child under the age of five. And there's certainly some variability as to how to manage these kids post-operatively in regards to how much pain medicine they will need and kind of require, but my approach is actually fairly similar, and we'll go through a little bit of that later today in the talk. The bottom line, children need pain medicine too. I have a lot of parents that are definitely a little averse to any kind of narcotic pain medicine, and there's a fine balance between medicating their child very safely, and what some parents in my community will worry about is addiction, and we'll talk a little more later too. I think bottom line are children just like adults, and the simple answer is no. Certainly we know that the hepatic metabolism of drugs varies by age of children. Additionally, neonates, infants, and really young children have a higher total body weight content and lower levels of plasma-binding proteins. And so opioids are highly protein-bound. And so in young children, opioid concentrations when they're abused may be at a higher concentration in these really young patients, and certainly that puts them at a little bit of risk for toxicity and overdose. I want to talk about pain in relation to a case. This is a case that occurred not too long ago at our hospital, but this is a nine-year-old male who was involved in a motor vehicle collision and sustained an open tibia fracture. He was splinted initially. Over the course of the night, he was admitted because he had some other injuries as well, including some rib fractures in the pneumothorax. Over the course of the evening, he had increasing pain as well as increasing narcotic requirements. The nurse had called, who was actually the general surgery trauma resident, but it certainly could have been one of our residents as well, and additional pain medicine kept being given to this child. Unfortunately, this is a child who the next morning was seen still pain completely uncontrolled, and what are some of the issues surrounding this? Well, one, this is a higher energy trauma. The patient has increasing pain and increasing pain medication requirements, and as the nurse had said earlier, and certainly when you see him the next morning, has significant anxiety too. So I want to just highlight briefly compartment syndrome. I'm not going to spend a lot of time on it, but I think it's important to talk about when you're talking about pain management in the acute trauma patient. The patient, unfortunately, he did go on to fixation, but also ended up with fasciotomy, and eventually skin graft as well on this leg after we were unable to close both his medial and lateral fasciotomy wounds. So compartment syndrome is an increased pressure within an enclosed osteofascial space, and so this decreases the capillary perfusion level below what is really needed for tissue viability. And there's really two mechanisms. One, either an increase in volume within that space or a decrease in the size of the space. It's about swelling, bleeding into compartments, which occurs with fractures, as well as splinting, casting, all can result and cause compartment syndrome. So we talked, there is an increased pressure, whether it's bleeding, swelling, or certainly we have seen it, too, with infusions as well that have extravasated, and so that pressure builds up, creating issues with perfusion of the surrounding muscle. Certainly you can decrease the volume overall, so external compression, tight dressings or splints, tight fascial closures, and that decrease, or excuse me, that increase in pressure can create it as well. There are lots of different causes. I'm not going to spend time on all this today, but I think it's important. Recognition is the most important part of compartment syndrome. It's really common. It's much more common in adults, but there's definitely data out there that suggests that compartment syndromes can and do occur in children as well, both in the upper as well as in the lower extremity. One of my areas of interest is supracondylar humerus fractures, and again, this is a common area, although it's not a common rate of compartment syndrome. When compartment syndrome develops, if it is something that is missed, it's completely devastating and can cause complete dysfunction that's permanent in the hand. So why is it missed? It is actually missed more frequently in kids than it is in adults. One, it's just not as common. It's not on our radar. Kids oftentimes have difficulty, a little bit more difficulty with exam because of communication, cooperation, or crime. Certainly, there's a component of fear. Some of these children may have a preexisting neurologic deficit. Bottom line, it presents differently in children. So it's important when we look at pain, in adults, the diagnosis oftentimes is just pain out of proportion or pain with passive stretch of the digits, whether it be the toes or the fingers. The remaining Ps that we see in the adult population usually occur late. In children, it's a little bit different presentation. Usually, it's more anxiety, agitation, and increasing pain medication requirement as we showed in our patient earlier. You can diagnose it clinically, or excuse me, you can diagnose it with pressure monitoring, but bottom line, compartment syndrome is a clinical diagnosis. So in children, you've really got to be aware when phone calls get made that pain is just not being controlled, especially when it's a medication that you feel like should control that patient's pain from the beginning. So in treating these, removing casts and dressing, placing the exterminate at the level of the heart to optimize perfusion. And then when you do have a suspicion, these are patients that need to go relatively quickly to the OR, or if they're severely injured, this oftentimes will happen in our brain injury patients. They're almost, quote, too sick to go to the OR. This is something that still needs to be addressed at the bedside. And we have done this in the ICU. And this is done emergently. When all of the fascia is released, we release all the compartments, whether it's in the lower leg, whether it's in the forearm, which are the two most common locations for compartment syndrome to develop. And so why is there such a big rush? Well, that swelling, that ischemia that we talked about, there is good basic science data that shows within about four to six hours, we have near irreversible changes after that period in regards to the skeletal muscle, as well as in regards to the peripheral nerves. And this is where that morbidity that we talked about earlier comes into play. There are lots of complications surrounding compartment syndrome. Certainly litigation is a concern as well. The biggest issue with litigation is the documentation. So when the nurse has documented that they called the physician, they called the physician, then they called them again, and all they're doing is increasing that pain medicine, and nobody's gone by to see the patient, that's when issues typically occur from a litigation perspective. The bottom line, as I said, early diagnosis is key. Being able to closely monitor their pain. So having a system in place that can closely monitor that as well with the nurses. Diagnosis is primarily clinical. And these are patients that are being transferred in from the outside hospital to an outside orthopedic surgeon, has suspicion of a compartment syndrome, they need to release those compartments. Every orthopedic surgeon that's board certified should be able to do this. The timing is the most important to prevent longer term morbidity. So why don't we talk about it with this particular talk, certainly I don't want to bore you with orthopedic issues, but for any provider that's taking care of trauma patients, this is important to recognize, especially early on. When these patients have, for children when they're having an increasing need for narcotics, it's got to be recognized early. And that's in the orthopedic realm, it's got to be recognized, but also in the general surgery trauma world as well. The other piece of it too is that I think it's important in a lot of these patients to avoid early nerve blocks. I'm not going to spend a lot of time on nerve blocks today. We do not routinely use these on a lot of our kids with lower extremity injuries that are polytrauma for this very reason. A nerve block may mask an acute compartment syndrome, and we certainly want to avoid that from a morbidity standpoint long term. So we'll talk a little bit now, which is sort of the nuts and bolts of this talk, is on pain management. Bottom line, I think this is almost my summary slide, but I don't just use opioids. It needs to be a multidisciplinary, multidrug approach, and certainly an alternative therapy approach to pain management in children. A lot of the literature that I'm going to show you is really based on adults. There's certainly some literature on pediatrics and some literature on the pediatric orthopedic world. I think it can be extrapolated some to the pediatric world and certainly to adolescents. So this is a little map of our world, and the United States consumes a large majority of the world's volume of opioids. And this is a major, major issue, and as I talked about, Dr. Hsu, this is one of his things that he stands up on a pulpit to speak about very, very frequently, and a lot of these initial slides are, again, from Dr. Hsu. Certainly, the death rate involving opioids has grown significantly over the last decade as well, and you can see this chart from 2003 to 2014, and the number of overdose deaths per 100,000. And now, this is not purely children, this is all comers, and again, the majority of these are adults. But unfortunately, we're seeing issues like this more and more in our pediatric population. You know, death is really just the tip of the iceberg. Certainly, abuse, misuse, and diversion are also issues involving our patients as well. I have had parents as well that have taken their children's narcotics at home. I certainly don't suspect all parents of that, but when you really feel like a patient should be off narcotics and they're requesting and calling in frequently for pain medicine, I think it's important to have that level of suspicion. So these are just a couple of headlines that I've found that have been, you know, in sort of the lay press as well as in some research more recently. But as we talked about, although this is a huge problem in the adult world, this is becoming more and more of an issue with opioid use in children as well. So this article talked about kids and teens hospitalized because of opioid abuse and how it's doubled since 1997. And this is truly an epidemic at this point for our nation. Again, this is another just lay press article on a child's overdose in a local neighborhood. Again, we've seen a significant increase in deaths in adolescents over the course of the last decade as well. The bottom line, this has to be something that we're recognizing and we have to do something about it. And I really believe that this starts in the more acute phase with how we manage pain initially for a lot of our patients. Opioid monotherapy has been around primarily in the U.S. for over the last 15 to 20 years. And a big part of this has been very much industry-driven as this is a huge, multibillion-dollar industry. Also, pain as a fifth vital sign was something that I think all of us interpreted from some of the JCAHO standards as we measured pain. JCAHO more recently has clarified that they did not declare pain as the fifth vital sign. And certainly that has been a misconception over the years, but that has driven a little bit of pain management, I think, in our country. There's also other misconceptions that risk of addiction is less than 1%. That's not necessarily the case. There are a number of papers that have looked at prescription drug abuse in chronic pain patients. And again, the majority of these papers are in the adult world, but a high rate of isogenic addiction for a lot of these patients, anywhere from 3% to about 45% risk of addiction. Certainly perioperative overdose is a concern, and certainly the use of naloxone is a concern as we've been increasingly using that as well. And that's likely more related to the higher dose and more frequency of opioids that are being used in the post-trauma, post-surgical world. I think this is really one of the slides and papers that really hit home for me, but this particular paper in 2011 found that 50% of patients taking opioids for at least three months are still on opioids at five years. And that is a huge number, and that makes this a huge problem within our country. Now again, the majority of these are adult patients, but we have had some issues even here in Oakland with just our adolescent patients. Certainly there are patients that are more acutely at risk for over-sedation, and this is really both adult and pediatric, a lot of these risk factors. I've kind of highlighted some of the ones that are a little bit more common in children. Certainly obesity, our polytrauma pediatric patients, patients requiring those increased opioids, first 24 hours after anesthesia. Certainly if they're getting other sedating agents on any kind of continuous opioid infusion also puts patients at a higher risk. Opioids, as a lot of people know, have other side effects, itching, sedation, nausea, vomiting, GI issues such as ileus, as well as respiratory depression. So it's a balance that we've got to find in pain management, balancing their comfort as well as safety and use of the pain medication. So meanwhile, the non-steroidal anti-inflammatory fear began. And so I wanted to talk a big part and kind of take home from an orthopedic standpoint, at least in our community, the big push towards the use of anti-inflammatories and NSAIDs and getting away from a higher dose of opioids, both in the younger patient and for us here in the adult world, getting away from it in the older patients as well. A lot of the issues that a lot of our general surgery colleagues here at orthopedics speak of is the issues with bone healing with NSAID use. And so this was an animal study using rats and looking at bone healing with ProxQ function and how an anti-inflammatory or an NSAID affected bone healing. What they found is that it clearly affected bone healing. And a lot of the literature early on surrounding this particular paper, this really changed a lot of people's practice. And I think, one, it scared a lot of orthopedic surgeons away from using NSAIDs. What's interesting is another surgeon did a study not too long ago that found the same issue with bone healing after opioid administration. And so it's probably not just the NSAID that caused that, but it did create quite the hysteria and certainly a lot of risk aversion to using NSAIDs in orthopedic patients. So you say, well, we're not treating rats. Well, here's the human data that's out there currently. And so, excuse me, let me go back to that. There are certainly some data that suggest that anti-inflammatories inhibit fracture healing. These are all clinical papers. But as you can see, the majority of the papers that support NSAIDs are not your highest level studies. The majority of these are retrospective level four studies. There are also a lot of studies that look at, or that found that there's no effect on bone healing. Again, some of these studies, you can see, are a little bit better level of evidence as four of the nine here listed are all randomized control trials, and the remaining are prospective or retrospectives. And so, bottom line, the results depend on the quality of the studies. And so when you really get down to the nitty gritty details of all these studies looking at anti-inflammatories, it is probably, there's probably no significant effect. And what I would tell you from a pediatric perspective, there is very, very little effect. Bone union is very much not an issue like it is in our adult colleagues and their patients. Biggest issues in the adult world, diabetes, the fact that a lot of these patients are smokers. We know that diabetes and smoking, nicotine, have a huge impact on bone healing. So certainly those are some of the confounding variables that my adult colleagues have to battle that I just don't have to battle as frequently in the pediatric world. Bone healing, non-union, or a bone that does not heal properly, is just not as much of an issue in the pediatric world. When we look at these from a meta-analysis standpoint, we really found that although there are certainly papers, as we talked about, that suggest some issues with bone healing, there are just as many papers that may suggest that bones unite without any issues related to insets. And again, when you look at the higher quality data only, so those randomized control trials, the odds ratio improves as well. So what about specifically TORADOL? When you really break down the papers looking specifically at just TORADOL, the data is very, very similar. This particular slide reviews essentially all the literature involving NSAIDs, and this includes both adult as well as pediatric studies and how it's broken down. You can see in a lot of papers there's really no clear recommendation. There's certainly some papers in the adult world that suggest that patients should not be on anti-inflammatories. So when you really look at just the pediatric studies as well, NSAIDs appear to be perfectly fine to use. And the enemy has really been us, and so we have really been the ones that have influenced this change in pain management over the last number of years, away from kind of anti-inflammatory use and probably more towards some of the opioids as well. And so, you know, certainly there are trauma patients and then there are post-surgical patients as well, and so this is a great study that looked at narcotic use after surgery and whether it's really needed. A lot of this and a lot of the pain management is probably driven partially by what people perceive as patient satisfaction as well as a little bit of sort of the cultural standard. And so in this particular paper, when you look at both hip fractures and ankle fractures, and again, this is an adult paper, you can see kind of our culture versus a different area of the world, the use of narcotic prescription for these injuries post-op is very, very different. So clearly in the United States, this opioid use is very much driven by us. And as far as patient satisfaction goes, this is a prospective observational study that looked at patient satisfaction, and satisfaction actually was a little bit higher in the Netherlands compared to the U.S., and very few opioids are used on a regular basis in the Netherlands. Traditional studies have shown that there's a greater reported pain with higher opioid use post-op, as well as decreased satisfaction in patients with higher opioid doses as well. And so opioid use does not necessarily improve patient satisfaction, or in our case, parental satisfaction as a lot of these, as frequently as the satisfaction of other parents that were taking care of their children. So from my perspective, I'll kind of briefly talk about just our inpatient multimodal approach, and this includes both a pharmaceutical approach, physical as well as cognitive approach and strategies. We'll talk first about the pharmaceutical piece. So bottom line is we talked about anti-inflammatories work after surgery, and that's been clearly shown in both the adult as well as the pediatric literature, that single doses of ibuprofen as well as Q8-hour doses of Tordol have clearly been shown to decrease pain and improve outcomes in individuals with fractures in the post-operative period. The Tordol is a medication that I use very, very frequently when indicating to my children, and I say when indicated, I would say the majority of the time it is indicated, unless there's a contraindication like severe asthma. I will use this in the post-operative period in essentially all of my patients. Clearly even as it's related to cancer, there's improved pain with the use of Tordol as well. In the pediatric literature, and this is not just fractures, some of this is posterior spinal fusions for scoliosis, the use of Ketorolac clearly has lower risk of complications compared to opioids only, lower rates of pain, and less post-op nausea after surgery. I definitely have found that a lot of the nausea is related more towards, related to how high of a dose of narcotics patients are on, and so I think managing their pain better with the NSAID will also help to decrease that nausea. Studies in the pediatric orthopedic world involving fractures have also found lower hospital stays when compared to morphine alone. This last study by Kay et al., which was recently published in 2010, looked at 221 fracture patients. They found no delayed unions, no malunion of the bone, no wound, and no bleeding complications. And although we have not done a study involving this at our institution, I would echo that study as well, that we very rarely see any complications related to our NSAID use. So typical dosing for me is 0.5 milligrams per kilogram. I typically do this scheduled TID with a max dose of 30 milligrams per dose, so certainly some of my larger adolescents, we have a large population of obesity, you know, these patients, the max dose for them is about 30 milligrams per dose. And again, I will continue this typically for about three days. There are some patients I will go a little bit longer. I do not routinely check any blood work. Certainly if there's some pharmacists that are listening, if they want to comment on anything, they certainly can at the end. But I do not routinely check any blood work in regards to cramping function or liver function while patients are on these medications. I will also transition patients when I feel like they've kind of maxed out on the Toradol. If they've been in the hospital for a while, I'll transition them to ibuprofen. I really like, and at least in my outpatient practice, I really like using naproxen. Naproxen seems to last a little bit longer, and I like using that in my adolescents, too, as you don't have to take it as frequently. I find that with Motrin, if they're needing to take it every six to eight hours, they usually forget doses during the daytime or have issues getting those doses, and so the naproxen works a little bit better as that's a Q12 hour drug. Certainly in my world, there are some patients that have some neuropathic pain, patients that have had nerve injuries, and so for those patients, I will occasionally use gabapentin. This is not something I routinely use on most of my pediatric orthopedic patients, but as recently as about four weeks ago, I had a patient with a concomitant elbow fracture as well as a nerve injury and was having a lot of neuropathic-type pain postoperatively. Instead of just increasing his dose of hydrocodone and morphine, we started him on gabapentin, but that really seemed to work, and we did not, and it was a low dose of it, so we didn't really have any complications related to gabapentin, and we avoided complications related to the higher opioid use. I do encourage, in any patients that we see and take care of more of a field block, you know, there is some data on doing a block of the fractured hematoma, which I think can also help some with pain. Certainly some of my adult colleagues are using more of the liposomal bupivacaine. We have not used that as routinely in the pediatric population, but I do think that that's something that we will likely look into in the future. There's some data using these cocktails, these liposomal bupivacaine cocktails, postoperatively in adult patients, the majority of people that had it done had lower narcotic use as well as lower pain scores, so I think that's something that we need to look into for management of fracture pain in a lot of these trauma patients. So this is an area that is not frequently talked about, I think, by most orthopedic surgeons, but it's the physical side. Ice is really important. I use ice very frequently on my trauma patients to apply ice over top of the affected area, and there's actually some pretty good data on cryotherapy as it slows cellular metabolism, delays nerve conduction. There's very good data, and a lot of my colleagues in sports medicine will use a lot of cryotherapy after ACL reconstructions and other surgeries like that. There's good data that it suppresses a lot of the tendon inflammation, certainly in an animal model. In my mind, there's very little harm to using ice on these patients postoperatively. It can decrease their pain, decrease their opioid requirements. Certainly there is a little bit of a variable effect that you'll see on patients depending on what type of injury it is, but it certainly can help immediately in a postoperative period. And in other areas, there's definitely data that suggests that it can help as well. This particular first study looked at improvement in pain with ice pack use after laparotomy. Improvement in pain associated with chest tube irritation, and certainly we have used it occasionally in patients in the pediatric world with rib fractures as well. But there's not a lot of data on that. The data does suggest that more continuous ice is better at nighttime than it is just applying an ice pack that's going to melt. I will tell you, some of these cryotherapy systems can be relatively expensive. I do not routinely use it. I primarily use more of a frozen bag of ice that can be re-frozen and re-used by the child. I don't use, for a lot of these trauma patients initially, I just don't use the bigger cryotherapy containers. A lot of the orthopedic patients have splints or casts on, and bottom line, you can change the skin temperature underneath these casts, bandages, and splints, and there's good data to suggest that as well, even in your bigger, bulkier dressings. I do use them on top of casts as well. The last thing that I wanted to talk about in regards to my kind of multi-modal approach is the cognitive piece. Both attentional, cognitive, affective, and social components clearly affect pain and pain perception in trauma patients. Certainly anxiety, or what we have termed, and others have certainly termed, pain catastrophizing, impacts how much a patient is having after trauma, how much pain a patient is having after trauma, as well as post-operatively. There are a lot of papers from a psychological standpoint that have looked at anxiety related to pain. So it's important to have more of a multi-modal approach in regards to alternative medicine as well. There's not as much data in these areas, but the way that I talk to my family is it can't hurt. So certainly, music, aroma, acupuncture, we don't routinely use acupuncture in the acute setting, but for more chronic pain, it has been shown to improve some pain and certainly decrease some of that anxiety. But what we do use at our institution, and these individuals are utilized really across the country in a lot of children's hospitals, is our child life specialists. So these are individuals that specialize in methods of child and family support during pediatric hospitalization. From a trauma perspective, any time we have a pediatric trauma that comes in, we have a child life specialist that's actually called to all of the traumas. So this individual is actually with the family. So in a lot of these major motor vehicle collisions and other bad trauma, there is somebody that is there for their support initially during that hospitalization. Child life specialists are very, very useful in the pediatric orthopedic world, useful in distracting patients, useful in decreasing the amount of anxiety that they have. And there have been some studies. This study was published in 2006 in the Journal of Pediatric Nursing and looked at improved patient cooperation with procedures and improved pain and anxiety level as well with the use of child life specialists. So I cannot comment enough on how valuable this piece is to management of pain in the post-operative period or post-trauma period as well. So again, this is sort of that overall look of what I do post-operatively for my patients. I do use opioids, so I'm not saying that we don't use any at all, but I certainly try to be as sparing as we can with this use. I am a high utilizer of NSAIDs. Very acutely, I use Tordol, and then I transition patients to ibuprofen that they can take at home. Certainly, if they're having any GI issues, we can look at other NSAIDs that may have a decreased risk for GI problems like meloxicam. Gabapentin is used relatively infrequently in my hands, but certainly can be used very effectively with neuropathic-type pain. I strongly recommend no sustained-release opioids. We never use those here in children. I rarely use any sedatives or hypnotics like Benzos, and rarely ever use Ambien. And then certainly, from that cognitive standpoint, having child life available, as well as using ice frequently on these patients. So when I send patients home, again, I do send them home typically with hydrocodone with the goal of weaning off of that relatively quickly. And there are clearly, there's data to show that a lot of patients with these orthopedic injuries can be off within about a week in the pediatric world. Certainly my adolescents are on it a little bit longer, but I am very aggressive in trying to talk with them early on about weaning, and really alternating their hydrocodone with their ibuprofen to wean off of all their medication, to wean off the hydrocodone completely, and then off of the Motrin over the coming weeks. So still afraid of NSAIDs? We're not here, and we've really gone, all of our pediatric orthopedic patients receive some form of NSAIDs when they're able to. I am not a believer of any delayed bone healing issues, certainly in the pediatric world. I am probably more worried about my adolescents in regards to opioid dependence, and certainly opioid-related deaths, although it's not as common in kids as it is in adults, it's still an issue. That's all I have on the pain perspective. Just briefly wanted to kind of go through sort of the pediatric approach to open fractures. There has been some changing literature over the course of the last number of years. So open fractures are really common. This is an 11-year-old gymnast who fell off the beam under her left arm. So you can see the open injury that she had. And so I'll talk briefly on sort of the initial management of these patients, antibiotic treatment as well as timing of surgery. She ended up going fairly quickly to surgery, and ended up getting an irrigation to bring up the wound, as well as close reduction when we pinned her. So there are fracture classification systems for open fractures, and so type 1 injuries, which are probably the most common, are typically less than a centimeter in length. These are very clean wounds. Type 2 is typically over a centimeter in length without any significant soft tissue damage. And then our type 3 is an extensive soft tissue damage, a crushing or traumatic amputation, and then there are subtypes to the type 3 as well. So a 3A has adequate soft tissue coverage, a 3B has inadequate soft tissue coverage, and a 3C has an associated arterial injury that requires repair. So you can see a few examples here. So type 1 is typically just a small poke hole. The type 2, again, is larger than a centimeter, a little bit higher energy injury. Type 3 is any high energy injury, and you can see how open that wound is. And then the type 3C is, again, with a vascular type injury. And why is this important? Well, this has been clearly related and shown that as you increase that open nature and increase the energy associated with these open fractures, there's an increased infection rate. So our type 3 open fractures are at a high risk for developing infection because of that associated soft tissue damage. So typically we don't recommend really probing the wound. You can pull on the skin to see if you can see any subcutaneous fat in a very small wound to see if that dermis is broken. And then these are injuries that need to be discussed with your own co-orthopedic surgeon. Probably the most important thing is the initiation of antibiotics. And so we know, based on a number of good studies that have been done, this particular study was published quite a while ago that was a prospective double-blind randomized study looking at infection rates and antibiotic use. And clearly, compared to placebo, there's decreased infection rates when antibiotics are utilized relatively soon in the care of these patients. So which antibiotic is also important? Typically first-generation cephalosporins are used in the type 1 injuries. In type 2 and 3, it is typically just a single drug with a cephalosporin, but occasionally if these are foreign-type injuries, we will add an aminoglycoside or even a third-generation cephalosporin as well. There is some controversy in this, though, and some of our staff feel strongly that penicillin and aminoglycosides are not really required, even for the foreign-type injuries. And the most important thing is the timing of antibiotics. And clearly, earlier timing with the antibiotics decreases your infection rate. Here at Carolinas Healthcare System, we have even gone and we're currently finishing up a pre-hospital study with a medic here looking at starting antibiotics while these open injuries are even en route to the hospital. We feel like that earlier delivery of antibiotics will help to decrease infection risk even more. So traditionally, these open fractures were called surgical emergencies that required immediate operative debridement and fracture stabilization, and that golden period of getting these done was within about 6 to 12 hours. Orthopedic surgeons, we work pretty hard, I think, but we also like to sleep, too, and we don't have to do something in the middle of the night. And so this is a paper looking at children that were surgically debrided within 6 hours versus 24 hours. And what we found is that really under 24 hours, there's a low infection risk, and 6 versus 24 hours, there's really no significant difference in the infection risk. So our goal is typically to get to these children within about 24 hours. Now, how urgent is urgent? Again, within 24 hours, no major difference. For type 2 and 3, these typically always require some form of surgical debridement. These are typically higher energy injuries with more devitalized tissue, and the injury to the soft tissue will certainly affect the local host defenses to resist infection. There is some controversy now in regards to open type 1 fractures. The type 1 injury is typically lower energy. Your zone of injury is also not as significant, and vascular supply is a little bit better to that area as well. So there's a decrease in the risk factors for true development of infection, which are devitalized tissue, ischemia, as well as edema. So there are a number of papers that have come out in the last number of years that have looked at non-operative management of type 1 open fractures in children. And the data is actually fairly good. Although this is just a retrospective study, there have been many other studies that have looked at patients, and there's a very low infection rate when treated these non-operatively. All these patients underwent an irrigation under some slight sedation in the emergency department, and then were placed into casts or splits appropriately afterwards. So although it is controversial, I think it's important, obviously, to call the on-call surgeons, see what their preference is to managing. But for us here at our institution, for a lot of the type 1 injuries, we consider these outpatient management. They undergo an ER irrigation and closed treatment for their fractures. They receive a single dose of IV antibiotics. There is no data on PO antibiotics at discharge, but I will say that a lot of pediatric attendings will send them out on about three to seven days of oral antibiotics. There are others that will manage these non-surgical, but will admit them for 24 hours of IV antibiotics. We don't routinely do that at our institution. Certainly, you can window a cast or splint over top of the wound so we can check it to make sure that there's no signs of infection. So again, most important thing is the prompt treatment of antibiotics, or prompt antibiotic use in these patients with open injuries. There is some controversy with the type 1 injuries, but this is likely changing across the country. But defer to your local orthopedic surgeon as to their preference for management. Certainly, if you have any questions, I'm happy to answer anything at this time. I think we have a few minutes for questions. But thank you for listening today, and I appreciate your time. Go ahead and type in your question or raise your hand. Everybody's asleep. I understand. I won't take it personally. Here's our first question. What areas are you aware of that are currently using antibiotics with EMS? At Carolina's Healthcare System, we have implemented that. Actually, my adult colleagues are studying that right now. So I don't know that that's being done across the country, but that's something that we've looked into. We're looking at a lot of studies that involve the pre-hospital care for patients. And so I think within Mecklenburg County, that's been instituted. It may not be with every single medic. They may be studying it more in a little bit of a randomized fashion. So if it's local people asking that question, it may not be in every single medic. But we are beginning to use that more routinely here at Carolina's Healthcare. And we have not a question, but a statement of excellent presentation. Thank you. Hawaii is saying thank you for their presentation. Aloha. Okay, we're going to go ahead and close out at this time. I'd like to thank Dr. Scanelli for a great presentation as well as the information on pain management and open fracture updates. As you digest the information today, please, if you have any questions, please let TCA know and we will forward those questions to him. Please don't forget to complete the evaluation following the program so we may continue to improve our offering. Thanks again for participating. And before we go on further, there is one more question. Does your ED prescribing group mirror your opiate prescribing practices? Good question. Say that one more time. That's a great question. So my partner, Dr. Hsu, has, and I couldn't tell you exactly how many dollars it is, but has a large grant through the CDC to specifically look at our system. So Carolina's Healthcare System, I don't know how many hospitals we have, 40 to 45 hospitals that were within our system. And lots of ERs that are associated with the hospitals and lots of freestanding ERs. And so I can't say that across our system that is mirrored. And our opinion within the orthopedic department is mirrored throughout. But I will tell you, Dr. Hsu is trying to get his message out to everybody within our system and really beyond. So we, within our electronic medical record in the last probably two years, Dr. Hsu has set up some stops that occur whenever individuals order narcotics. And so if it's been within our system, you'll get a prompt that says that a patient should have 50% of their narcotics still remaining on the last prescription that was given. And what that does, it allows the provider to really make that clinical decision at that point. You know, is this a patient I really need to give narcotics to? Or is this a patient that really should have enough and maybe is drug seeking? Or should have enough and maybe we need to focus on NSAID use? You know, I can't say that everybody across the system echoes our feeling on things. But we're certainly trying to get it that way to improve management and decrease opioid use really across the system. Thank you. Great question. Our next webinars will be in September. September 21st will be How to Deal with Mock Trauma. And then following up in October 26th will be a finance webinar. So once again, thank you for participating in today's webinar.

pediatric orthopedic patient

pain management

webinar

Dr. Brian Scannell

non-opioid medications

multidisciplinary approach

distraction techniques

open fractures

surgical intervention