|SYMPOSIUM ON PEDIATRIC TRAUMA
|Year : 2012 | Volume
| Issue : 3 | Page : 143-148
Perioperative management of pediatric trauma patients
Yulia Ivashkov, Sanjay M Bhananker
Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
|Date of Web Publication||12-Sep-2012|
Department of Anesthesiology and Pain Medicine, Harboview Medical Center 325 Ninth Avenue Box 359724, Seattle, WA 98104
| Abstract|| |
Pediatric trauma presents significant challenges to the anesthesia provider.
This review describes the current trends in perioperative anesthetic management, including airway management, choice of anesthesia agents, and fluid administration.
The review is based on the PubMed search of literature on perioperative care of severely injured children.
Keywords: Children, management, pediatric, perioperative, trauma
|How to cite this article:|
Ivashkov Y, Bhananker SM. Perioperative management of pediatric trauma patients. Int J Crit Illn Inj Sci 2012;2:143-8
| Introduction|| |
Traumatic injuries remain to be a major cause of death in children from 1 to 14 years old in the US. Forty-five percent of total mortality in this age group is due to trauma. Motor vehicle collisions (59% mortality from all accidents in age group 5-14), pedestrian and bicycle accidents, falls, burns, and physical assault are the most common causes of injury in children.  Many of injured children will require surgical treatment with involvement of the anesthesiologist.
The anesthesia providers may have to take care of pediatric patients on following occasions:
Therefore, anesthesia providers should be familiar with the principles of management of pediatric trauma as well as with age-related specific anatomical and physiological aspects of trauma care.
- Initial stabilization in the emergency department
- Providing sedation and monitoring for imaging
- Emergent surgical procedures such as laparotomy or craniotomy
- Semielective surgeries after initial stabilization such as long bone fracture fixations
- Intensive care unit management of these patients
- Pain control during hospitalization, especially using regional analgesia
| Anesthetic Management|| |
Preoperative evaluation and management
Whenever possible, a thorough history and medical examination should be conducted prior to anesthetic administration. However, in urgent procedures only brief history outlined by AMPLE mnemonic may be feasible.
A = Allergies
M = Medications
P = Past medical history
L = Last oral intake, last tetanus immunization
E = Events related to the injury
Clinical examination is the most important diagnostic tool in pediatric trauma.  In emergency, only a quick assessment of airway, breathing and circulation could be possible.
The preparation of the operating room should include stocking the anesthesia cart with age-appropriate equipment, diluting and labeling the medications in age-appropriate doses, and raising the ambient temperature to 26°C for infants and small children. 
Rapid-infusion devices, fluid warmers and infusion pumps should be available.
Imaging and laboratory testing may be very useful in injured children, but they should not delay emergent procedures. From all the chest imaging methods, standard anterior-posterior chest X-rays is a cost-effective screening tool that will reveal most of the thoracic abnormalities. 
Routine laboratory tests such as urinalysis or serum chemistries are rarely indicated in pediatric trauma. From the specific testing, type and cross match blood, and hematocrit are indicated for a hemodynamically unstable patient. Serial hematocrits may help in the monitoring of solid organ injuries.  Since coagulopathy is associated with trauma in general and with head injuries specifically,  PT, PTT, and INR are useful tests in critically injured patients.
Serial arterial blood gas testing is invaluable in assessing dynamic changes in hematocrit, oxygenation and acid-base status in critically ill children.
Airway assessment and management
Many of the trauma victims arrive to the emergency department already intubated. In this case the anesthesiologist` duty is to assess the airway (tube size, cuffed/incuffed, presence and magnitude of air leak if uncuffed tube, depth of the tube, breath sounds, ventilation and oxygenation). Any chest X-ray done in the emergency department should be reviewed for the correct position of the tracheal tube in mid-trachea, and for the presence of pneumothoraces.
Children have high oxygen consumption rate, relatively low functional residual capacity, and rapid bradycardic response to hypoxia. They do not tolerate long apneic periods well. Therefore, thorough airway examination is crucial. The anesthesia provider should be prepared to encounter the following anatomical features of pediatric airway:
Equipment necessary for intubation include: functioning suction, age-appropriate tracheal tubes with stylets, functioning laryngoscope (straight and curved blades). A secondary device for tube placement confirmation (e.g., capnograph, colorimetric CO 2 detector) should also be available. If the child needs to be intubated, he/she should be given 100% O 2 prior to intubation to denitrogenate the lungs. This increases the O 2 reserve and allows a longer period of apnea during intubation. The cervical spine should be protected with a spinal board and rigid collar. If an appropriate pediatric cervical collar is not available, rolled towels or blankets might be carefully placed on either side of patient's head in young children and infants. Peripheral intravenous or intraosseous access should be checked for correct positioning prior to injecting medications.
- A large protuberant occiput creates the natural flexion of the head in young children. It predisposes the airway to obstruction, and requires careful positioning for intubation. In cases when neck stabilization is needed, a large occiput can make the airway management even more challenging.
- A small oral cavity, large tongue, delicate easy-bleeding gums, the presence of adenoids and tonsils, and occasionally loose deciduous teeth may restrict intraoral manipulation, obstruct visibility with direct laryngoscopy, and create predisposition to easy bleeding.  Nasotracheal intubation or even use of a nasal airway can cause hemorrhage.
- The larynx is short and positioned relatively high and more anterior. The epiglottis is often U-shaped, long, and floppy. This combination may pose potential difficulties with laryngoscopy, and a short larynx increases the possibility of endobronchial intubation.
- One should also be aware of the fact that a pediatric airway is at its narrowest at the cricoid cartilage when choosing the endotracheal tube.
The pediatric trauma victims should always be considered as full stomach patients, and rapid sequence induction is preferred. Rapid sequence induction is a gold standard for airway management in these patients. 
Aerophagia and gastric inflation are characteristic for children with trauma and/or assisted ventilation with a bag valve mask. Besides, traumatic gastric paresis may significantly slow down gastric emptying even if the last meal was more than 8 hours ago. After initiation of sedation, cricoid pressure is recommended to prevent gastroesophageal reflux, though the utility of cricoid pressure is debated. Cricoid pressure is contraindicated in patients with suspected cricotracheal injury, active vomiting, or unstable cervical spine injuries. 
A sample protocol for rapid sequence intubation is presented in [Figure 1]. 
|Figure 1: A potential scenario-based protocol for rapid sequence intubation in children. From Zelicof-Paul A, Smith-Lockridge A, Schnadower D, Tyler S, Levin S, Roskind C, et al. Controversies in rapid sequence intubation in children, with permission|
Click here to view
Severely injured children may be intubated with either cuffed or uncuffed endotracheal tubes. The general opinion, however, is shifting in favor of using cuffed tubes, even in the prehospital settings. , The size of the uncuffed tube is often determined by modified Cole formula (age [y]/4+4 mm ID), and is decreased by half-size for cuffed endotracheal tubes. The cuff should be inflated to get a seal at about 25 cm H 2 O of airway pressure.
Induction drugs may vary, but Etomidate 0.1-0.2 mg kg−1 is a preferable induction agent in hypovolemic patients with a head injury. Etomidate provides hemodynamic stability and decreases cerebral oxygen consumption, which makes it a desirable agent despite possible influence on adrenocortical system.
Benzodiazepines, ketamine, thiopental, and propofol can also be used when appropriate. ,, Characteristics of induction agents appropriate for rapid sequence induction in children are represented in [Table 1]. 
|Table 1: Characteristics of preferred intravenous sedative agents for rapid sequence induction|
Click here to view
Fast muscle relaxation could be achieved with succinylcholine or rocuronium.
Alternative devices in case of failed laryngoscopy may include a videolaryngoscope  and laryngeal mask airway (LMA).  Fiber optic bronchoscopy and intubation may be performed later via the LMA. 
| Intraoperative Management|| |
Monitoring should be adjusted to specific needs. Temperature monitoring is mandatory in all children due to their immature thermoregulation, disproportionately greater body surface area to body mass ratio and fluid and heat loss from exposed surgical sites. Children with a head injury may require arterial and intracranial pressure monitoring as well as neurophysiologic monitoring during surgery. Noninvasive monitoring devices, including continuous hemoglobin analysis and near infrared spectrometry, are being increasingly used in pediatric anesthesia and may have a role in the care of trauma patients. 
The maintenance of anesthesia should follow the principles of balanced anesthesia and provide adequate hypnosis, analgesia and muscle relaxation. No single technique is superior to others. , Isoflurane, sevoflurane, and continuous intravenous infusion of propofol and opioids have all been used safely.  However, the total intravenous anesthesia technique is gaining popularity, especially during neurosurgical procedures. 
Intraoperative fluid management
Physiologically, children compensate better hemodynamically in the early stages of injury. Hypotension is a late sign of hemorrhage in children that may not occur until 25-35% of the blood volume or more is lost.  Tachycardia is the first sign of hypovolemia in children, and it should not be overlooked, because children have small blood volumes (80 ml kg−1 in an infant 1-3 months old, 70 ml kg−1 in children older than 3 month  ), and delay in fluid resuscitation may lead to a significant hypovolemia fast.
All intravenous fluids should be warmed to 37° to prevent hypothermia.
Resuscitation routinely begins with clear fluid, isotonic crystalloids being the fluid of choice. The end-points of fluid resuscitation in children usually include normalization of pulse rate and urine output >1 ml kg−1 h−1 .
Hypertonic saline was shown to increase hemodynamic stability and decrease fluid requirements in adult trauma patients,  but it did not affect the survival rate.  One might consider use of hypertonic saline when trauma is associated with a closed head injury;  however, more evidence for use of hypertonic saline in children is needed.  Hydroxyethil starch and albumin have also been used in children with no significant adverse effects. ,
Dextrose-containing fluids are usually avoided, because hypotonic solutions may contribute to the development of cerebral edema,  and also to avoid risk of hyperglycemia, which is associated with poor neurological outcome in children with a head injury.  However, hypoglycemia also is harmful for a suffering brain, and should be avoided. 
Guidelines regarding transition from clear fluids to blood and blood products are not well established in pediatric trauma. Clinical decisions either follow adult protocols, or are made per individual clinical judgment. , Deciding on time and volume of blood transfusion may be difficult in children. Underresuscitation leads to impending shock, when hemodilution, coagulopathy, acidosis and transfusion-related complications are associated with excessive crystalloid infusion and administration of blood products. The concept of damage control resuscitation (DCR)  has been associated with improved survival and shorter hospital stay in adults. 
The core principles of DCR include rapid surgical control of bleeding, permissive modest hypotension that helps preserving the freshly formed thrombus, minimal use of isotonic coloids with prevention of hemodilution-related complications, and early administration of packed red blood cells (PRBC) in combination with plasma, and platelets in a 1: 1: 1 unit ratio.  Supplemental use of coagulation factors such as recombinant factor VII and or cryoprecipitate is advocated if appropriate. DCR may be applicable to pediatric traumatic hemorrhage;  however, more clinical data is needed.
As of now, recommendations on starting blood transfusion in injured children include administration of two fluid boluses of 20 ml/kg each followed by whole blood or packed red blood cells if no improvement in clinical status is seen. 
Massive transfusion may be required in cases of severe trauma. An example of massive transfusion protocol in a 5-year-old patient (70 ml/kg circulating blood volume) has been described as replacement for the first lost blood volume with crystalloid, 30 ml kg−1 PRBCs, and 20 ml kg−1 fresh frozen plasma. Each consequent circulating blood volume lost was replaced with PRBCs, fresh frozen plasma and platelets in a 3: 2: 2 volume ratio. 
The large surface to weight ratio predisposes children to heat loss. Immature thermoregulation mechanism and effects of general anesthesia can lead to rapid development of hypothermia.  Ambient temperature is an important factor influencing heat loss. However, maintaining the operating room at 30°C at all times can cause significant discomfort to a surgical team. Therefore, minimizing body exposure to ambient air and use of active warming are essential. Warming blankets, heated humidified air, and reduction of evaporative losses all offer modest benefits in reduction of heat loss. Convection heaters effectively warm children when body surface area uncovered is 20% or more.  Heat loss can also be prevented with administration of warm intravenous fluids. 
One should be aware of risk of hyperthermia with all warming techniques, therefore monitoring of core temperature is necessary.
| Emergence and Postoperative Period|| |
Most of the children with polytrauma will require monitoring and further stabilization in the intensive care unit (ICU) after the initial surgery. Significant fluid shift, acidosis, and soft tissue swelling could be anticipated with massive blood loss and aggressive fluid resuscitation. A combination of prolonged prone position and significant amount of intravascular fluids may cause airway swelling and abdominal compartment syndrome.  Many of these patients will require continuation of mechanical ventilation in the ICU. If decision on extubation in the operating room after polytrauma is made, it must be considered carefully. Longer cases and younger age were associated with early extubation failure after pediatric cardiac surgery. 
Successful extubation in patients receiving mechanical ventilation is dependent on cardiovascular stability, normal acid-base balance, presence of intact airway reflexes and ability to clear secretions, an intact central inspiratory drive, ability to exchange gases efficiently, and respiratory muscle strength to meet the work associated with respiratory demand.  Upper airway obstruction is the single most common cause of extubation failure.  In pediatric trauma patients, mechanism of injury (facial burn vs. other) and absence of an air leak at the time of extubation are the strongest factors predicting postextubation stridor. Patients with one or both risk factors require special attention to airway management and may not be good candidates for an early extubation.  Children who cannot be extubated immediately, will require transport to the intensive care unit and possibly to the imaging facilities.
Multiple mishaps with physiologic deterioration during transport have been described. , Before transport, anesthesiologist should reassess the patient and ensure hemodynamic stability, adequate oxygenation, and functionality of the monitors. Intraoperative monitoring should be continued during transport, and the resuscitation drugs should be immediately available. A detailed report containing history and perioperative events must be given to the intensive care unit team, ensuring the continuity of care and patient safety.
Children, who were successfully extubated postoperatively, require a regimen of careful pain control. Treating pain may reduce anxiety and fear, which can themselves exacerbate pain.  It was shown previously, that very young children were more likely to receive inadequate analgesia compared with older children.  Acetaminophen is a commonly used drug. The recommended oral dosage is 10-15 mg per kilogram every four hours for children. Rectal administration produces delayed and variable uptake. Subsequent rectal doses should be smaller (e.g., 20 mg per kilogram), and the interval between doses should be extended to at least 6-8 hours.  Ibuprofen was shown to be more effective than acetaminophen in treating pain from musculoskeletal trauma.  In case more analgesia is needed, careful titration to effect of morphine or other opioids should be used. In infants 3-6 months of age, the analgesic effects of morphine or fentanyl are similar to, and the ventilatory depression is no greater than, that seen in adults with similar plasma concentrations.  Therefore, opioids should not be withheld in young children. Recently, regional anesthesia has been utilized with a great effect for post-operative pain treatment. Ultrasonographic guidance for a broad spectrum of regional anesthetic techniques results in safe and effective blocks of both upper and lower extremities. , Ropivacaine and levobupivacaine are less toxic than bupivacaine, and can be safely used in children. 
| Summary|| |
Trauma is a leading cause of morbidity and mortality in children. Anesthesiologists are widely involved in care of injured children during admission to the emergency department, surgical intervention, and postoperative care. Knowledge and understanding of different aspects of pediatric trauma allows anesthesia providers to be efficient and safe in their practice.
| References|| |
|1.||Heron M, Hoyert DL, Murphy SL, Xu J, Kochanek KD, Tejada-Vera B. Deaths: Final data for 2006. Natl Vital Stat Rep 2009;57:1-134. |
|2.||Dykes EH. Paediatric trauma. Br J Anaesth 1999;83:130-8. |
|3.||Varon AJ, Smith CE, editors. Essentials of trauma anesthesia. Cambridge: Cambridge University Press; 2012. |
|4.||Renton J, Kincaid S, Ehrlich PF. Should helical CT scanning of the thoracic cavity replace the conventional chest x-ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis. J Pediatr Surg 2003;38:793-7. |
|5.||Linzer J. Do routine laboratory tests add to the care of the pediatric trauma patient? Clin Pediatr Emerg Med 2010;11:4. |
|6.||Hymel KP, Abshire TC, Luckey DW, Jenny C. Coagulopathy in pediatric abusive head trauma. Pediatrics 1997;99:371-5. |
|7.||DeRoss AL, Vane DW. Early evaluation and resuscitation of the pediatric trauma patient. Semin Pediatr Surg 2004;13:74-9. |
|8.||Sagarin MJ, Chiang V, Sakles JC, Barton ED, Wolfe RE, Vissers RJ, et al. Rapid sequence intubation for pediatric emergency airway management. Pediatr Emerg Care 2002;18:417-23. |
|9.||Landsman I. Cricoid pressure: Indications and complications. Paediatr Anaesth 2004;14:43-7. |
|10.||Zelicof-Paul A, Smith-Lockridge A, Schnadower D, Tyler S, Levin S, Roskind C, et al. Controversies in rapid sequence intubation in children. Curr Opin Pediatr 2005;17:355-62. |
|11.||Clements RS, Steel AG, Bates AT, Mackenzie R. Cuffed endotracheal tube use in paediatric prehospital intubation: Challenging the doctrine? Emerg Med J 2007;24:57-8. |
|12.||Newth CJ, Rachman B, Patel N, Hammer J. The use of cuffed versus uncuffed endotracheal tubes in pediatric intensive care. J Pediatr 2004;144:333-7. |
|13.||Bledsoe GH, Schexnayder SM. Pediatric rapid sequence intubation: A review. Pediatr Emerg Care 2004;20:339-44. |
|14.||Paal P, Herff H, Mitterlechner T, von Goedecke A, Brugger H, Lindner KH, et al. Anaesthesia in prehospital emergencies and in the emergency room. Resuscitation 2010;81:148-54. |
|15.||Fonte M, Oulego-Erroz I, Nadkarni L, Sanchez-Santos L, Iglesias-Vasquez A, Rodriguez-Nunez A. A randomized comparison of the GlideScope videolaryngoscope to the standard laryngoscopy for intubation by pediatric residents in simulated easy and difficult infant airway scenarios. Pediatr Emerg Care 2011;27:398-402. |
|16.||Levy RJ, Helfaer MA. Pediatric airway issues. Crit Care Clin 2000;16:489-504. |
|17.||Tunkel DE, Fisher QA. Pediatric flexible fiberoptic bronchoscopy through the laryngeal mask airway. Arch Otolaryngol Head Neck Surg 1996;122:1364-7. |
|18.||Campbell S, Wilson G, Engelhardt T. Equipment and monitoring--What is in the future to improve safety? Paediatr Anaesth 2011;21:815-24. |
|19.||Szabo EZ, Luginbuehl I, Bissonnette B. Impact of anesthetic agents on cerebrovascular physiology in children. Paediatr Anaesth 2009;19:108-18. |
|20.||Engelhard K, Werner C. Inhalational or intravenous anesthetics for craniotomies? Pro inhalational. Curr Opin Anaesthesiol 2006;19:504-8. |
|21.||Hans P, Bonhomme V. Why we still use intravenous drugs as the basic regimen for neurosurgical anaesthesia. Curr Opin Anaesthesiol 2006;19:498-503. |
|22.||Schwaitzberg SD, Bergman KS, Harris BH. A pediatric trauma model of continuous hemorrhage. J Pediatr Surg 1988;23:605-9. |
|23.||Barcelona SL, Thompson AA, Cote CJ. Intraoperative pediatric blood transfusion therapy: A review of common issues. Part II: Transfusion therapy, special considerations, and reduction of allogenic blood transfusions. Paediatr Anaesth 2005;15:814-30. |
|24.||Younes RN, Aun F, Accioly CQ, Casale LP, Szajnbok I, Birolini D. Hypertonic solutions in the treatment of hypovolemic shock: A prospective, randomized study in patients admitted to the emergency room. Surgery 1992;111:380-5. |
|25.||Bulger EM, May S, Kerby JD, Emerson S, Stiell IG, Schreiber MA, et al. Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock: A randomized, placebo controlled trial. Ann Surg 2011;253:431-41. |
|26.||Morrow SE, Pearson M. Management strategies for severe closed head injuries in children. Semin Pediatr Surg 2010;19:279-85. |
|27.||Doyle JA, Davis DP, Hoyt DB. The use of hypertonic saline in the treatment of traumatic brain injury. J Trauma 2001;50:367-83. |
|28.||Sumpelmann R, Kretz FJ, Gabler R, Luntzer R, Baroncini S, Osterkorn D, et al. Hydroxyethyl starch 130/0.42/6:1 for perioperative plasma volume replacement in children: preliminary results of a European Prospective Multicenter Observational Postauthorization Safety Study (PASS). Paediatr Anaesth 2008;18:929-33. |
|29.||Standl T, Lochbuehler H, Galli C, Reich A, Dietrich G, Hagemann H. HES 130/0.4 (Voluven) or human albumin in children younger than 2 yr undergoing non-cardiac surgery. A prospective, randomized, open label, multicentre trial. Eur J Anaesthesiol 2008;25:437-45. |
|30.||Kaieda R, Todd MM, Cook LN, Warner DS. Acute effects of changing plasma osmolality and colloid oncotic pressure on the formation of brain edema after cryogenic injury. Neurosurgery 1989;24:671-8. |
|31.||Cochran A, Scaife ER, Hansen KW, Downey EC. Hyperglycemia and outcomes from pediatric traumatic brain injury. J Trauma 2003;55:1035-8. |
|32.||Udani V, Munot P, Ursekar M, Gupta S. Neonatal hypoglycemic brain - Injury a common cause of infantile onset remote symptomatic epilepsy. Indian Pediatr 2009;46:127-32. |
|33.||Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, et al. Management of bleeding following major trauma: An updated European guideline. Crit Care 2010;14:R52. |
|34.||Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg 2010;19:286-91. |
|35.||Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3 rd , Fruchterman TM, Kauder DR, et al. 'Damage control': An approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35:375-82; discussion 82-3. |
|36.||Duchesne JC, Barbeau JM, Islam TM, Wahl G, Greiffenstein P, McSwain NE Jr. Damage control resuscitation: from emergency department to the operating room. Am Surg 2011;77:201-6. |
|37.||Spinella PC, Holcomb JB. Resuscitation and transfusion principles for traumatic hemorrhagic shock. Blood Rev 2009;23:231-40. |
|38.||Browne GJ, Cocks AJ, McCaskill ME. Current trends in the management of major paediatric trauma. Emerg Med (Fremantle) 2001;13:418-25. |
|39.||Paterson NA. Validation of a theoretically derived model for the management of massive blood loss in pediatric patients - A case report. Paediatr Anaesth 2009;19:535-40. |
|40.||Imrie MM, Hall GM. Body temperature and anaesthesia. Br J Anaesth 1990;64:346-54. |
|41.||Cassey JG, Armstrong PJ, Smith GE, Farrell PT. The safety and effectiveness of a modified convection heating system for children during anesthesia. Paediatr Anaesth 2006;16:654-62. |
|42.||Bernardo LM, Gardner MJ, Lucke J, Ford H. The effects of core and peripheral warming methods on temperature and physiologic variables in injured children. Pediatr Emerg Care 2001;17:138-42. |
|43.||Cravero JP, Muffly M. Case presentation: Abdominal compartment syndrome complicating posterior spinal fusion. Paediatr Anaesth 2012;22:278-80. |
|44.||Mittnacht AJ, Thanjan M, Srivastava S, Joashi U, Bodian C, Hossain S, et al. Extubation in the operating room after congenital heart surgery in children. J Thorac Cardiovasc Surg 2008;136:88-93. |
|45.||Thiagarajan RR, Bratton SL, Martin LD, Brogan TV, Taylor D. Predictors of successful extubation in children. Am J Respir Crit Care Med 1999;160:1562-6. |
|46.||Newth CJ, Venkataraman S, Willson DF, Meert KL, Harrison R, Dean JM, et al. Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 2009;10:1-11. |
|47.||Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Crit Care Med 1991;19:352-5. |
|48.||Paret G, Ben Abraham R, Yativ O, Vardi A, Barzilay Z. [Intrahospital transport of critically ill children]. Harefuah 1999;136:609-11. |
|49.||Wallen E, Venkataraman ST, Grosso MJ, Kiene K, Orr RA. Intrahospital transport of critically ill pediatric patients. Crit Care Med 1995;23:1588-95. |
|50.||Schechter NL, Blankson V, Pachter LM, Sullivan CM, Costa L. The ouchless place: No pain, children's gain. Pediatrics 1997;99:890-4. |
|51.||Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med 2003;41:617-22. |
|52.||Berde CB, Sethna NF. Analgesics for the treatment of pain in children. N Engl J Med 2002;347:1094-103. |
|53.||Clark E, Plint AC, Correll R, Gaboury I, Passi B. A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics 2007;119:460-7. |
|54.||Oberndorfer U, Marhofer P, Bosenberg A, Willschke H, Felfernig M, Weintraud M, et al. Ultrasonographic guidance for sciatic and femoral nerve blocks in children. Br J Anaesth 2007;98:797-801. |
|55.||Kapral S, Greher M, Huber G, Willschke H, Kettner S, Kdolsky R, et al. Ultrasonographic guidance improves the success rate of interscalene brachial plexus blockade. Reg Anesth Pain Med 2008;33:253-8. |