Bisso Raoul, Tielli Alexandra, Lopes Anne-Aurelie
From the Emergency Department, Paris Saint-Joseph Hospital Group (Bisso), the Paediatric Emergency Department, AP-HP, Robert Debre Hospital University, Paris University (Tielli), and the Paediatric Emergency Department, AP-HP, Necker-Enfants-Malades University Hospital, Paris University, Paris, France (Lopes).
J Am Acad Orthop Surg. 2024 Dec 15;32(24):e1280-e1288. doi: 10.5435/JAAOS-D-24-00231. Epub 2024 Aug 30.
Pain management in orthopaedic manipulation in the emergency department (ED) is crucial to decrease fracture reduction performed in the operating room. This study compared intranasal fentanyl (INF) with oral morphine in time of care and effectiveness on pain during the reduction of bone fractures in a pediatric trauma center.
A before-and-after INF implementation study was conducted in a pediatric ED with a trauma center on children with a confirmed displaced closed fracture on radiographs with reduction and casting performed in the ED. The time of care, time for sufficient analgesia, effectiveness on pain, and tolerance were compared between both analgesics in 3 consecutive phases.
77 children were included: 31 children received oral morphine and 46 INF. The time of care was shorter in the INF group (150 [111 to 193] minutes versus 215 [155 to 240], P = 0.01) as the time for sufficient analgesia (10 [9 to 13] minutes versus 80 [53 to 119], P < 0.001) with a higher pain reduction after a dose of INF (3 [0 to 4] versus 6 [3 to 7], P < 0.001) and less dose requirement ( P = 0.002). Although pain scores were similar at arrival in both groups ( P = 0.15), the pain was significantly lower before and during the procedure in the INF group and equivalent after the procedure (2 [0 to 4] versus 3 [0 to 5], P = 0.02, 3 [1 to 5] versus 7 [3 to 9], P < 0.001, and 1 [0 to 2] in both groups, P = 0.87, respectively). Keeping pain levels low during the procedure in the INF group allowed the extension to lower limb fracture reductions ( P = 0.04). No serious adverse events were reported.
INF reduces the time to obtain sufficient analgesia and time of care, with good effectiveness maintained during the procedure in fracture reduction, allowing the extension to lower limb fractures. Thus, this rapid and efficient analgesia facilitates orthopaedic care in the pediatric ED that would otherwise require to be reduced in the operating room under general anesthesia.
急诊科骨科手法操作中的疼痛管理对于减少在手术室进行的骨折复位至关重要。本研究在一家儿科创伤中心比较了鼻内给予芬太尼（INF）和口服吗啡在骨折复位时的护理时间及对疼痛的缓解效果。
在一家设有创伤中心的儿科急诊科开展了一项INF应用前后的研究，研究对象为经X线片确诊为闭合性移位骨折且在急诊科进行复位和石膏固定的儿童。在连续3个阶段比较了两种镇痛药的护理时间、达到充分镇痛的时间、对疼痛的缓解效果及耐受性。
共纳入77名儿童：31名儿童接受口服吗啡，46名接受INF。INF组的护理时间更短（150[111至193]分钟对215[155至240]分钟，P = 0.01），达到充分镇痛的时间也更短（10[9至13]分钟对80[53至119]分钟，P < 0.001），一剂INF后的疼痛缓解程度更高（3[0至4]对6[3至7]，P < 0.001）且剂量需求更少（P = 0.002）。尽管两组到达时的疼痛评分相似（P = 0.15），但INF组在操作前和操作期间的疼痛明显更低，操作后相当（分别为2[0至4]对3[0至5]，P = 0.02；3[1至5]对7[3至9]，P < 0.001；两组均为1[0至2]，P = 0.87）。INF组在操作期间将疼痛水平维持在较低水平，使得下肢骨折复位的范围得以扩大（P = 0.04）。未报告严重不良事件。
INF可缩短获得充分镇痛的时间和护理时间，在骨折复位操作过程中保持良好的效果，使下肢骨折复位范围得以扩大。因此，这种快速有效的镇痛方法有助于儿科急诊科的骨科护理，否则这些操作需要在全身麻醉下于手术室进行。
