Injury, Int. J.

Care Injured 45 (2014) 845–849

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Analgesia in the management of paediatric and adolescent trauma

during the resuscitative phase: The role of the pediatric trauma centre
Ram V. Anantha a, Tanya Charyk Stewart b, Aarthi Rajagopalan a, Jillian Walsh a,
Neil H. Merritt a,b,*
a
Department of Surgery, Western University, London, Ontario, Canada
b
Trauma Program, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada

A R T I C L E I N F O A B S T R A C T

Article history: Background: The objective of this study was to evaluate the use of analgesia in the resuscitative phase of
Accepted 19 October 2013 severely injured children and adolescents.
Methods: A retrospective cohort of paediatric (age < 18 years), severely injured (ISS  12) patients were
Keywords: identified from the London Health Sciences Centre’s Trauma Registry from 2007 to 2010. Variables were
Analgesia compared between Analgesia and Non-analgesia groups with Pearson Chi-square and Mann–Whitney U
Paediatric trauma tests. Resuscitative analgesia use was assessed through multivariable logistic regression controlling for
Primary survey
age, gender, mechanism, arrival and Trauma Team Activation (TTA).
Trauma Team Activation
Outcome study
Results: Analgesia was used in 32% of cases. Univariate analysis did not reveal any differences in gender,
age, injury type, injury profile and arrival patterns. Significant differences were found with analgesia
used more frequently in patients injured in a motor vehicle collision (58% vs. 42%, p = 0.026) and having
parents in the resuscitation room (17% vs. 6%, p = 0.01). Analgesia patients were more injured (median
ISS 22 vs. 17, p = 0.027) and had 2.25 times more TTA (39% vs. 17%). Logistic regression revealed patients
arriving directly to a trauma centre had a higher incidence of receiving analgesia (OR 2.01, 95% CI: 1.03–
3.93), as did TTA (OR 2.18, 95% CI: 1.01–4.73) and having parents in resuscitation room (3.56, 95% CI:
1.23–10.33). Narcotics were most commonly used (85%), followed by benzodiazepines (16%), with 66%
given during the primary survey.
Conclusion: Use of analgesia is important in the acute management of paediatric trauma. Direct
presentation to a level I trauma centre, TTA and the presence of parents lead to higher appropriate use of
analgesia in paediatric trauma resuscitation.
Crown Copyright ß 2013 Published by Elsevier Ltd. All rights reserved.

Introduction severity in children by both clinicians and parents [13], parental

Trauma is the leading cause of morbidity and mortality among
children under the age of fifteen years in North America [1,2], with
significant social and economic implications [3,4]. Despite signifi-
cant evidence about the benefits of early and adequate control of
injury-related pain [5–8], the underuse of analgesics and sedatives
in paediatric trauma patients remains pervasive [7,9–12]: children
are given analgesics less often than adults for similar conditions,
and they are often prescribed a fraction of the weight-based
equivalent of analgesics [9]. Reasons for the low usage of pain
control in paediatric trauma include poor judgement of pain
* Corresponding author at: Division of Pediatric Surgery, Children’s Hospital,
London Health Sciences Centre, 800 Commissoners Road East, London, Ontario,
Canada N6A 5W9. Tel.: +1 519 685 8454; fax: +1 519 685 8465.
E-mail addresses: neil.merritt@lhsc.on.ca, merritt.n@gmail.com (N.H. Merritt).
concerns about the risks and benefits of pain medications [14], and
a potential lack of comfort among physicians treating paediatric
patients [8]. The objective of our study was to investigate the use of
analgesia during the early resuscitative phase in severely injured
paediatric trauma patients managed at our pediatric trauma
centre.
Methods
After obtaining institutional review board approval, we
conducted a retrospective analysis from our trauma registry of
all paediatric (age < 18 years old) trauma admissions to the
Children’s Hospital, London Health Sciences Centre (LHSC),
between January 2007 and December 2010. The Children’s
Hospital (LHSC) is a Trauma Association of Canada (TAC)-certified
level I pediatric trauma centre (PTC) in Southwestern Ontario. All
trauma deaths in the paediatric emergency room (ER) were

0020–1383/$ – see front matter . Crown Copyright ß 2013 Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.injury.2013.10.048
846 R.V. Anantha et al. / Injury, Int. J. Care Injured 45 (2014) 845–849

included in the database for this study. Deaths on arrival (DOAs; 3
patients) were excluded. An Injury Severity Score (ISS) was
assigned to each patient retrospectively after identification of all
injuries [15,16], and all patients whose ISS was greater than or
equal to 12 were included. An ISS  12 is also the inclusion criteria
for the Comprehensive Data Set of the Ontario Trauma Registry for
severe or major injury treated at trauma centres in the province of
Ontario. We excluded two patients, who were admitted directly to
the Pediatric Critical Care Unit (PCCU) without resuscitation in the
ER, and five patients whose resuscitation forms were incomplete
either at our institution or the peripheral hospital from which they
were transferred. The registry was reviewed with respect to
patient age, gender, mechanism, intensive care unit (ICU)
admission, need for operative intervention, ISS, maximum
abbreviated injury scale (MAIS) by body region, analgesia use,
and mortality. A retrospective chart review was also performed on
all included patients to determine the type and amount of
analgesia administered during the primary and secondary survey
of the initial resuscitation based on ER records and Trauma Team
notes. Given the large size discrepancy among the paediatric and
adolescent population, the adequacy of analgesia dosage was
calculated based on whether the patient received the appropriate
weight-based dose of medication. Although developmental stage
can also affect the adequacy of analgesia use [11], we were unable
to accurately obtain this information for all patients; consequently,
we could not evaluate its significance in the context of this study.
Continuous data were expressed as median (interquartile
range; IQR; 25–75 percentile), and categorical variables were
reported as frequencies and percentages. Continuously-distributed
variables were compared using the Mann–Whitney U test, as the
data were non-normally distributed, while categorical variables
were compared using the Pearson chi-square test, or Fisher’s exact
test (when small cell sizes were present). In univariate analysis, we
evaluated the association of the use or non-use of analgesia or
sedation with other independent variables: age, gender, mecha-
nism of trauma, method of arrival (either directly to the PTC or
transfer from a referral hospital), and Trauma Team Activation
(TTA).
Multivariable analysis was performed using a logistic regres-
sion model to estimate the odds ratio (OR) and the 95% CI of
administering analgesia to severely injured paediatric patients
during the early resuscitative phase. Calibration of the logistic
model was assessed using the Hosmer–Lemeshow goodness-of-fit
test [17] to evaluate the importance of the discrepancy between
the observed and expected usage of analgesia. All statistical
analyses were performed using Predictive Analytics SoftWare
(PASW) Statistics 18 (SPSS, Chicago, IL). p values less than 0.05
were considered significant.
Results
There were 203 patients meeting our inclusion criteria
(Table 1), with 64 patients (32%) and 139 patients (68%) in the
analgesia and non-analgesia groups respectively. Both groups were
similar with respect to age, gender distribution, comorbidities, and
method of arrival at the trauma centre (Table 1). However, the
mechanism of trauma, the proportion of Trauma Team Activation
(TTA), and the presence of parents in the resuscitation room,
differed significantly between the two groups: MVCs accounted for
58% of the group receiving analgesia, but only 42% of the non-
analgesia group (p = 0.026, x2c ¼ 9:29), whereas falls comprised
only 9% and 27% of the analgesia and non-analgesia groups
respectively (p = 0.026, x2c ¼ 9:29). TTA occurred in 39% of the
analgesia group, but only in 17% of the non-analgesia group
(p = 0.001, x2c ¼ 14:9). Parents were present in 17% of resuscita-
tions in the analgesia group, compared to 6% in the non-analgesia
group (p = 0.010). The analgesia group had a higher median ISS
compared to the non-analgesia group (22 vs. 17 in the non-
analgesia group, p = 0.027). When the injuries were scored
according to the maximum abbreviated injury scale (MAIS) for
each body region, there were no statistically significant differences
(Table 1), with the exception of external skin injuries. With respect
to the latter, there was a statistical difference (p = 0.002), even
though the median MAIS score was 1 for both groups. There was
also a statistical (p = 0.012), but not clinical, difference in GCS on
arrival to the trauma centre, with a median score of 15 for both
groups.
Among those who received analgesia, 43 patients (67%) were
given pain control during the primary survey while 21 patients
(33%) received analgesia during the secondary survey. A distribu-
tion of the types of analgesia administered during resuscitation is
presented in Fig. 1. The use of the non-analgesic sedatives
etomidate and propofol among all patients was 4% and 5%
respectively: 14% of patients receiving analgesia also received

Table 1
Univariate analysis comparing analgesia and non-analgesia groups of severely injured paediatric patients treated at LHSC between 2007 and 2010.

Variable Analgesia (n = 64) Non-analgesia (n = 139) p value

Median age, years (IQRa) 14 (4–16) 11 (5–16) 0.273

Male gender, n (%) 44 (69) 105 (76) 0.309

Mechanism, n (%) 0.026

MVC 37 (58) 58 (42)
Falls 6 (9) 38 (27)
Intentional 5 (8) 13 (9)
Other 16 (25) 30 (22)
Direct arrival 28 (44) 45 (33) 0.156
Trauma Team Activation (TTA) 25 (39) 24 (17) 0.001
Parents in resuscitation room 11 (17) 8 (6) 0.010
Co-morbidities 21 (33) 34 (25) 0.213

Median ISS (IQRa) 22 (16–29) 17 (16–25) 0.027

Median MAIS score by region (IQRa)
Head 4 (3–5) 4 (4–5) 0.840
Face 2 (1–3) 1 (1–2) 0.142
Chest 3 (3–3) 3 (3–4) 0.202
Abdomen 3 (2–4) 4 (3–4) 0.068
Extremities 3 (2–3) 3 (2–3) 0.692
External 1 (1–3) 1 (1–1) 0.002
Median Glasgow Coma Scale on arrival at trauma centre (IQRa) 15 (13–15) 15 (15–15) 0.012

The p values for statistically significant comparisons are highlighted in bold.

a
Inter-quartile range (25–75%).
[(Fig._1)TD$IG] R.V. Anantha et al. / Injury, Int. J. Care Injured 45 (2014) 845–849 847

100

80

Percentage of patients receiving medication (%)

60

40

20

s
n

ne
e

ol
s

he
s

in

at
tic

ID

of
pi
op
m

id
co

SA

op
ze
ta

om
in
ar

Pr
ia
Ke
N

am

Et
N

od
et

nz
Ac

Be

Analgesics Sedatives
Medication

Fig. 1. Distribution of analgesics and sedatives given to severely injured paediatric trauma patients who received pain control during the early resuscitative phase.

Table 2
Comparison of the clinical outcomes among the analgesia and non-analgesia groups revealed differences in the length of time spent in the emergency room, and lengths of
stay in the intensive care unit (ICU) and in the hospital.

Outcome Analgesia (n = 64) Non-analgesia (n = 139) p value

Median length of time in emergency room, min (IQRa) 141 (86–222) 195 (101–327) 0.015
Complications, n (%) 13 (20) 28 (20) 0.978
Hypotension, n (%) 3 (5) 12 (9) 0.587

Disposition post-resuscitation, n (%) 0.083

Operating room 8 (13) 12 (9)
Pediatric Critical Care Unit (PCCU) 34 (53) 54 (39)
Ward 21 (33) 72 (52)
Other Lead Trauma Hospital 1 (2) 1 (1)

Mortality, n (%) 3 (5) 11 (8) 0.555

Median length of stay in ICU, day (IQRa) 3 (1–10) 1 (1–3) 0.003
Median length of hospital stay, day (IQRa) 6 (4–15) 4 (3–7) <0.001

Discharge disposition, n (%) 0.318

Home 37 (61) 95 (74)
Home with support services 14 (23) 17 (13)
Acute care facility 1 (2) 3 (2)
Rehabilitation facility 6 (10) 8 (7)
Foster care 3 (5) 3 (2)
Other 0 (0) 2 (2)

The p values for statistically significant comparisons are highlighted in bold.

a
Interquartile range (25–75%).
848 R.V. Anantha et al. / Injury, Int. J. Care Injured 45 (2014) 845–849
Table 3
Multivariable logistic regression analysis of analgesia use in severely injured paediatric trauma patients demonstrated statistically-significant correlations between the
presence of parents in the resuscitation room, direct arrival to the specialised pediatric trauma centre, and Trauma Team Activation.
Variable Ba
Age 0.004
Parents in resuscitation room 1.27
Motor vehicle collision (MVC) 0.38
Direct arrival to pediatric trauma centre 0.70
Trauma Team Activation (TTA) 0.78
ISS 0.024
The p values for statistically significant comparisons are highlighted in bold.
a
Regression coefficient in the logistic regression model.
b
Standard error of the regression coefficient.
etomidate, while 10% of the analgesia group was concurrently
given propofol (Fig. 1). Ten patients (5% of all patients) received
benzodiazepines (midazolam and lorazepam), but all of them also
received analgesics. Six patients (9%) received oral analgesia,
whereas 52 patients (81%) received parenteral analgesia. In six
patients (10%), the route of analgesic administration was not
recorded. Eighty-one percent of patients (n = 52) received the
adequate weight-adjusted dose of analgesia.
Differences between the two groups were observed for several
clinical outcomes (Table 2). Patients who received analgesia spent
significantly less time in the ER compared to the non-analgesia
group (a difference of 54 min, p = 0.015). However, the analgesia
group stayed longer in the critical care unit (a median of 3 days vs.
1 day; p = 0.003) and in hospital (a median of 6 days vs. 4 days;
p < 0.001). There were no statistically significant differences in
mortality (p = 0.555) or disposition on discharge from the hospital
(p = 0.318). The multivariable-adjusted odds of receiving analgesia
(Table 3) was statistically significant for parental presence in the
resuscitation room (OR 3.56, 95% CI: 1.23–10.33), direct arrival to
the trauma centre (OR 2.01, 95% CI: 1.03–3.93), and Trauma Team
Activation (OR 2.18, 95% CI: 1.01–4.72).
Discussion
Despite being one of the most common symptoms in trauma
[6,8,18], the treatment of pain remains insufficient in a majority of
paediatric patients with musculoskeletal injuries [19], burns [20],
and multi-system trauma [21]. Moreover, the adverse physiologi-
cal and psychological consequences of inadequate pain manage-
ment persist long after discharge [11,22]. In our study, early
analgesia usage in severely injured children is significantly
increased by direct arrival to a pediatric trauma centre (PTC),
Trauma Team Activation (TTA), and parental presence in the
resuscitation room.
The rate of analgesia use at our institution was only 32%, lower
than a previous study [21] where 48% of trauma patients received
opioids upon arrival to a PTC. In our univariate and multivariable
analyses, however, direct arrival to our PTC was associated with
significantly higher analgesia use compared to patients who
initially presented to a peripheral hospital (Table 3). Reasons for
this discrepancy may include reduced exposure to paediatric
trauma compared to a PTC, and apprehension about administering
analgesics to children for fear of causing complications, losing the
ability to perform adequate neurological assessments, or missing
progressing injuries. In our study, both groups had similar rates of
complications, including hypotension and respiratory depression,
which are known side-effects of many analgesics [12,19].
Additionally, the injuries sustained, and/or the mechanism of
trauma itself, were severe enough that all patients in our study
required radiological investigations such as computed tomography
(CT) scans of the head, chest, abdomen, and/or the pelvis,
irrespective of their neurological status. Since all our patients
SEb Odds ratio (OR) 95% CI p value
0.028 1.00 0.95–1.06 0.894
0.54 3.56 1.23–10.33 0.020
0.38 1.46 0.69–3.10 0.319
0.34 2.01 1.03–3.93 0.042
0.39 2.18 1.01–4.72 0.048
0.020 1.02 0.98–1.07 0.248
are closely followed by an inpatient paediatric trauma service, we
did not observe an increased incidence of missed injuries in the
analgesia group. Therefore, the careful and individualised use of
analgesics in severely injured children and adolescents does not
increase their morbidity or mortality.
Activation of the trauma team (TTA) also resulted in signifi-
cantly increased analgesic use among severely injured children, an
observation that has not been previously reported. A coordinated
resuscitation effort by multiple paediatric subspecialties, with
greater experience managing pain in different body regions, likely
led to an increased awareness of providing analgesia for the patient
during a TTA. While patient disposition may have been affected by
delays on the part of accepting services, the presence of the trauma
team and the subspecialties which generally accept trauma
patients (including general and orthopaedic surgery, neurosurgery,
and the paediatric critical care unit) significantly reduced the time
spent in the emergency room (ER), an observation that has been
reported in other studies [23]. Nevertheless, a prospective study
that examines the reasons for withholding analgesics during
resuscitation may provide further insight into their under-
utilisation.
We also show for the first time in the literature that the
presence of parents in the resuscitation room is a significant
predictor for analgesia usage during early resuscitation in
paediatric trauma. Although many ERs routinely exclude family
members because of concerns about the negative impact on
clinical care, the presence of parents does not affect the
appropriate and timely resuscitation of paediatric trauma patients
[24], and is not associated with long-term psychological trauma
[25]. In our study, parents may have advocated for analgesia during
the early resuscitation because they had a better sense of their
child’s pain compared to healthcare professionals [26,27]. Their
presence may have also helped to reduce anxiety in patients, and
may have served as an additional non-pharmacological interven-
tion to alleviate pain. A larger prospective study is needed to
determine if the presence of family members improves clinical
outcomes in paediatric trauma; the results from our study,
however, encourage the establishment of guidelines for family
presence during resuscitations.
While the mechanism of injury and severity of sustained
injuries differed between the two groups, neither variable was
significant in the multivariable analysis. Similar to other observa-
tional studies [2,28], motor vehicle collisions (MVCs) and falls were
the most common mechanisms of trauma in our study, increasing
the likelihood that these patients would receive analgesia
compared to other mechanisms. Although the higher Injury
Severity Score in the analgesia group translates to an additional
injury of moderate severity, such as a 3-cm laceration to the spleen
or liver [29], patients in the non-analgesia group also had injuries
that were severe enough to cause significant pain. In addition, both
groups had the same severity of head injuries and median GCS, so
the level of consciousness cannot explain the decision to withhold
 R.V. Anantha et al. / Injury, Int. J. Care Injured 45 (2014) 845–849
analgesia. These findings suggest that clinicians will administer
analgesia if the injuries are severe enough, and that analgesia use is
poor even in the absence of contraindications.
Similar to other studies [7,10,18], opiates (morphine and
fentanyl) were the most common analgesics administered to
patients in our study, followed by non-steroidal anti-inflamma-
tory drugs (NSAIDs), ketamine, and acetaminophen (Fig. 1).
Regional nerve blocks were not performed at our institution
during the study period, and their use during the resuscitative
phase in multi-system trauma patients is unclear [30]. Nine
percent of patients received oral analgesia, which is not as
effective as parenteral medication because of decreased bioavail-
ability, altered gastrointestinal tract motility, and nausea or
vomiting. Because of the size and developmental differences
among children and adolescents, the adequacy of analgesia given
was based on whether patients received the appropriate weight-
adjusted dose. Twenty percent of patients did not receive an
adequate dose, emphasising the importance of accurate drug-
monitoring when administering analgesics. The use of sedatives
with minimal analgesic properties, such as propofol [31],
etomidate [32], and benzodiazepines [32], was low in our study,
although a higher proportion of patients in the analgesia group
received sedation. We observed that sedatives were not only used
as anaesthetic agents for procedures such as intubations, but also
for neurologically intact patients. This finding suggests that
physicians may be administering sedatives as a way of reducing,
or even replacing, the need for analgesia.
Our study is limited by its retrospective nature. While we were
able to ascertain the type and amount of analgesia used, we were
not able to identify the reasons or circumstances surrounding the
lack of analgesic usage in patients. Moreover, it is unclear whether
the increased use of analgesia translated to improved pain control
for patients during their hospital stay. Prospective studies may
help answer these important questions, and address specific fears
and concerns that physicians may have when giving analgesics to
injured children.
Conclusions
In conclusion, we report that the direct arrival of severely
injured paediatric trauma patients to a specialised pediatric
trauma centre, activation of the trauma team, and the presence
of parents in the resuscitation room, significantly increases the use
of analgesics during the early resuscitative phase. The findings of
this study underscore the critical importance of the pediatric
trauma centre and the trauma team in managing of one of the most
common symptoms in trauma. Moreover, this study may provide
the impetus to conduct more focused prospective studies to help
optimise the use of analgesia in such a vulnerable population.
Conflict of interest
The authors do not have any conflicts of interest to declare.
References
[1] Ramenofsky ML. Pediatric abdominal trauma. Pediatric Annals 1987;16:
318–26.
849
[2] Diamond IR, Parkin PC, Wales PW, Bohn D, Kreller MA, Dykes EH, et al.
Preventable pediatric trauma deaths in Ontario: a comparative population-
based study. The Journal of Trauma 2009;66:1189–95.
[3] Krug EG, Sharma GK, Lozano R. The global burden of injuries. American Journal
of Public Health 2000;90:523–6.
[4] Grivna M. Injuries among children—some cost considerations in USA. Central
European Journal of Public Health 2001;9:109–12.
[5] Anand KJ, Hickey PR. Halothane–morphine compared with high-dose sufen-
tanil for anesthesia and postoperative analgesia in neonatal cardiac surgery.
The New England Journal of Medicine 1992;326:1–9.
[6] Hedderich R, Ness TJ. Analgesia for trauma and burns. Critical Care Clinics
1999;15:167–84.
[7] Cimpello LB, Khine H, Avner JR. Practice patterns of pediatric versus general
emergency physicians for pain management of fractures in pediatric patients.
Pediatric Emergency Care 2004;20:228–32.
[8] Cummings EA, Reid GJ, Finley GA, McGrath PJ, Ritchie JA. Prevalence and source
of pain in pediatric inpatients. Pain 1996;68:25–31.
[9] Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency
department: patterns of analgesic utilization. Pediatrics 1997;99:711–4.
[10] Friedland LR, Kulick RM. Emergency department analgesic use in pediatric
trauma victims with fractures. Annals of Emergency Medicine 1994;23:203–7.
[11] Greenwald M. Analgesia for the pediatric trauma patient: primum non
nocere? Clinical Pediatric Emergency Medicine 2010;11:28–40.
[12] Rupp T, Delaney KA. Inadequate analgesia in emergency medicine. Annals of
Emergency Medicine 2004;43:494–503.
[13] Singer AJ, Gulla J, Thode Jr HC. Parents and practitioners are poor judges of young
children’s pain severity. Academic Emergency Medicine 2002;9:609–12.
[14] Spedding RL, Harley D, Dunn FJ, McKinney LA. Who gives pain relief to
children? Journal of Accident & Emergency Medicine 1999;16:261–4.
[15] Baker SP, O’Neill B, Haddon Jr W, Long WB. The injury severity score: a method
for describing patients with multiple injuries and evaluating emergency care.
The Journal of Trauma 1974;14:187–96.
[16] Eichelberger MR, Gotschall CS, Sacco WJ, Bowman LM, Mangubat EA, Low-
enstein AD. A comparison of the trauma score, the revised trauma score, and
the pediatric trauma score. Annals of Emergency Medicine 1989;18:1053–8.
[17] Hosmer DW, Lemeshow S, Sturdivant, Rodney X. Applied logistic regression.
2nd ed. Manhattan, NY: Wiley; 2004.
[18] Donald C, Duncan R, Blair L, Thakore S, Clark M. Paediatric analgesia in the
emergency department, are we getting it right? European Journal of Emer-
gency Medicine 2007;14:157–9.
[19] O’Donnell J, Ferguson LP, Beattie TF. Use of analgesia in a paediatric accident
and emergency department following limb trauma. European Journal of
Emergency Medicine 2002;9:5–8.
[20] Singer AJ, Thode Jr HC. National analgesia prescribing patterns in emergency
department patients with burns. The Journal of Burn Care & Rehabilitation
2002;23:361–5.
[21] Neighbor ML, Honner S, Kohn MA. Factors affecting emergency department
opioid administration to severely injured patients. Academic Emergency
Medicine 2004;11:1290–6.
[22] Zonneveld LN, McGrath PJ, Reid GJ, Sorbi MJ. Accuracy of children’s pain
memories. Pain 1997;71:297–302.
[23] Stafford PW, Blinman TA, Nance ML. Practical points in evaluation and
resuscitation of the injured child. The Surgical Clinics of North America
2002;82:273–301.
[24] O’Connell KJ, Farah MM, Spandorfer P, Zorc JJ. Family presence during pediatric
trauma team activation: an assessment of a structured program. Pediatrics
2007;120:e565–74.
[25] Mangurten J, Scott SH, Guzzetta CE, Clark AP, Vinson L, Sperry J, et al. Effects of
family presence during resuscitation and invasive procedures in a pediatric
emergency department. Journal of Emergency Nursing 2006;32:225–33.
[26] Rajasagaram U, Taylor DM, Braitberg G, Pearsell JP, Capp BA. Paediatric pain
assessment: differences between triage nurse, child and parent. Journal of
Paediatrics and Child Health 2009;45:199–203.
[27] Whipple JK, Lewis KS, Quebbeman EJ, Wolff M, Gottlieb MS, Medicus-Bringa M,
et al. Analysis of pain management in critically ill patients. Pharmacotherapy
1995;15:592–9.
[28] Diamond IR, Parkin PC, Wales PW, Bohn D, Kreller MA, Dykes EH, et al.
Pediatric blunt and penetrating trauma deaths in Ontario: a population-based
study. Journal of Pediatric Surgery 2009;44:981–6.
[29] AAAM.. The abbreviated injury scale 2005, updated 2008. Barrington IL, USA:
Association for the Advancement of Automotive Medicine; 2008.
[30] Wambold D. Regional anesthesia in trauma. New York: CRC Press; 2007.
[31] Fassoulaki A. Is propofol an analgesic? European Journal of Anaesthesiology
2011;28:481–2.
[32] Reddy S, Patt RB. The benzodiazepines as adjuvant analgesics. Journal of Pain
and Symptom Management 1994;9:510–4.