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Pediatr Emerg Care. 2004 Apr;20(4):228-32.

Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients.

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Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, USA.



To determine if there are actual differences between pediatric emergency medicine (PEM) physicians and general emergency medicine (GEM) physicians in the management of pain in pediatric patients with fractured extremities.


Retrospective chart review of children seen with a forearm or lower extremity fracture over a 2-year period at 3 emergency departments (1 staffed by PEM physicians and 2 staffed by GEM physicians). A severe fracture was defined as a closed fracture with the presence of angulation or displacement. Procedural sedation was defined as the administration of medicine (sedative, analgesic, or dissociative anesthetic) at the time of reduction and/or immobilization of a fracture.


Of the 718 charts reviewed, PEM physicians managed 428 patients, and GEM physicians managed 290 patients. There were no significant differences between the patients managed by PEM physicians and GEM physicians with regard to age, sex, site of fracture, and proportion of severe fractures. There were no differences in the administration of analgesic-related medicines between PEM physicians and GEM physicians in the management of all fractures [40% (95% CI 35-45%) vs. 43% (95% CI 37-49%)] or severe fractures [58% (95% CI 51-64%) vs. 66% (95% CI 58-73%)]. In the management of all fractures, procedural sedation was used by PEM physicians in 100 [23% (95% CI 19-27%)] patients and by GEM physicians in 52 [18% (95% CI 14-23%)] patients. When procedural sedation was used, PEM physicians were more likely to use a sedative agent than GEM physicians [94% (95% CI 88-97%) vs. 46% (95% CI 33-59%)], fentanyl as opposed to morphine or meperidine [62% (95% CI 52-71%) vs. 19% (95% CI 33-59%)] and a combination of sedative and analgesic [90% (95% CI 83-94%) vs. 44% (95% CI 31-57%)]. For all fractures, GEM physicians documented recommending pain medications on discharge more often than PEM physicians [66% (95% CI 60-71%) vs. 45% (95% CI 40-50%)], and they prescribed significantly more prescription analgesics than PEM physicians [13% (95% CI 10-17%) vs. 2% (95% CI 1-4%)].


In our study, most children with an extremity fracture and greater than one-third of children with a severe fracture did not receive pain medications in the emergency department. Overall, both PEM physicians and GEM physicians have similar practices of analgesic administration for fracture reduction, with a notable exception in the types of agents used during procedural sedation. GEM physicians documented discharge pain medications and prescribed prescription analgesics more often than PEM physicians.

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