We explored caregiver perspectives on their children&... more We explored caregiver perspectives on their children's pain management in both a pediatric (PED) and general emergency department (GED). Study objectives were to: (1) measure caregiver estimates of children's pain scores and treatment; (2) determine caregiver level of satisfaction; and (3) determine factors associated with caregiver satisfaction. This prospective survey examined a convenience sample of 97 caregivers (n=51 PED, n=46 GED) with children aged <17 years. A paper-based survey was distributed by research assistants, from 2009-2011. Most caregivers were female (n=77, 79%) and were the child's mother (n=69, 71%). Children were treated primarily for musculoskeletal pain (n=41, 42%), headache (n=16, 16%) and abdominal pain (n=7, 7%). Using a 100 mm Visual Analog Scale, the maximum mean reported pain score was 75 mm (95% CI: 70-80) and mean score at discharge was 39 mm (95% CI: 32-46). Ninety percent of caregiver respondents were satisfied (80/89, 90%); three (3/50, 6%) were dissatisfied in the PED and six (6/39, 15%) in the GED. Caregivers who rated their child's pain at ED discharge as severe were less likely to be satisfied than those who rated their child's pain as mild or moderate (p=0.034). Despite continued pain upon discharge, most caregivers report being satisfied with their child's pain management. Caregiver satisfaction is likely multifactorial, and physicians should be careful not to interpret satisfaction as equivalent to adequate provision of analgesia. The relationship between satisfaction and pain merits further exploration.
A 33-y-old male developed severe acidosis, renal failure, and profound neutrophilia after ingesti... more A 33-y-old male developed severe acidosis, renal failure, and profound neutrophilia after ingesting ethylene glycol. Workup for his neutrophilia excluded infectious and malignant causes. An elevated leukocyte alkaline phosphatase (LAP) level confirmed a leukemoid response, and the neutrophila resolved. Although several leukemoid reactions have been published due to therapeutic agents these reports are often incomplete or inaccurate; this is the first case of leukemoid response to a toxin. Leukemoid response is distinguishable from leukemia by the absence of clonally derived cells, although this is not easily apparent in extreme neutrophilia. Elevated LAP is useful in identifying leukemoid reaction from leukemia in cases of extreme neutrophila. If a patient develops extreme neutrophila in association with drug or toxin exposure, a leukemoid reaction should be considered and an LAP obtained.
During childhood, pain often is experienced on a nearly daily basis. This study focuses on pain a... more During childhood, pain often is experienced on a nearly daily basis. This study focuses on pain alleviation techniques provided by parents, because children's painful experiences are most often treated at home. Hypotheses addressed various factors that can influence use of pain alleviation techniques, including parents' level of catastrophizing about their children's pain, children's age, and conversations with health care professionals. A total of 756 parents of children ages 6 to 17 years completed an online survey regarding pain alleviation including use and effectiveness of pharmacological and nonpharmacological techniques, pain catastrophizing, and questions regarding dialogue with health care professionals. Parents with increased pain catastrophizing used more pharmacological techniques, and child self-administration of pain alleviation techniques increased with the child's age. Parents were more likely to have spoken with their health care professional about pharmacological techniques. This study provides information that can help health care professionals initiate conversations regarding treatment options and align recommendations with techniques that parents are likely to use, and it can help health care professionals provide supportive alternative recommendations.
Painful procedures are common in the ED setting and beyond. Although these procedures are often e... more Painful procedures are common in the ED setting and beyond. Although these procedures are often essential to patient management, they can also be distressing for children, parents, and health providers. As such, it is imperative that effective pain and anxiety-minimizing strategies be used consistently in all settings where painful procedures take place for children. This review article aims to provide a summary of several strategies, which are supported by definitive and systematically reviewed evidence, that can be implemented alone or in combination to reduce procedural pain and anxiety for children in the ED and beyond. For neonates, breastfeeding, nonnutritive sucking, swaddling, and sucrose administration have all been shown to decrease pain during painful interventions. For neonates, venipuncture is much less painful than heel lance for blood draws. For infants, there is some support for sucrose use. For infants and older children, there is strong evidence for distraction techniques. In addition, the use of fast-acting topical anesthetic creams as an alternative or adjunct to infiltrating anesthetic before laceration repair or vascular access/venipuncture is recommended. Further, buffering of lidocaine can decrease pain during injection. Lastly, if a laceration is amenable to the use of tissue adhesive, this should be preferentially used. In summary, there currently remains a knowledge-to-practice gap in the treatment of children's procedure-related pain. This article has identified multiple age-specific methods to improve the treatment of procedural pain. These simple interventions can improve the care provided to ill and injured children.
Objective This study aims to determine the frequency that umbilical venous catheters (UVCs) and p... more Objective This study aims to determine the frequency that umbilical venous catheters (UVCs) and peripherally inserted central catheters (PICCs) migrate into the cardiothymic silhouette after initial verification of correct placement. Study Design This is a single-center, retrospective study in neonates in whom a PICC or UVC was placed. The frequency of catheter tip migration into the cardiothymic silhouette requiring catheter manipulation was determined radiographically at 1 and 24 hours, respectively, after insertion. Results At 1 and 24 hours, 36 and 23% of UVCs (n = 41) migrated into the cardiothymic silhouette, respectively. At 1 and 24 hours, 23 and 11% of PICCs (n = 63) migrated into the cardiothymic silhouette, respectively. Migration was not associated with birth weight, weight at insertion, or postnatal age at insertion. Conclusion UVCs and PICCs frequently migrate into the cardiothymic silhouette increase the risk for development of a pericardial effusion. Serial radiographic assessment of catheter tip location is needed to assess catheter migration within the first 24 hours of line placement.
We explored caregiver perspectives on their children&... more We explored caregiver perspectives on their children's pain management in both a pediatric (PED) and general emergency department (GED). Study objectives were to: (1) measure caregiver estimates of children's pain scores and treatment; (2) determine caregiver level of satisfaction; and (3) determine factors associated with caregiver satisfaction. This prospective survey examined a convenience sample of 97 caregivers (n=51 PED, n=46 GED) with children aged <17 years. A paper-based survey was distributed by research assistants, from 2009-2011. Most caregivers were female (n=77, 79%) and were the child's mother (n=69, 71%). Children were treated primarily for musculoskeletal pain (n=41, 42%), headache (n=16, 16%) and abdominal pain (n=7, 7%). Using a 100 mm Visual Analog Scale, the maximum mean reported pain score was 75 mm (95% CI: 70-80) and mean score at discharge was 39 mm (95% CI: 32-46). Ninety percent of caregiver respondents were satisfied (80/89, 90%); three (3/50, 6%) were dissatisfied in the PED and six (6/39, 15%) in the GED. Caregivers who rated their child's pain at ED discharge as severe were less likely to be satisfied than those who rated their child's pain as mild or moderate (p=0.034). Despite continued pain upon discharge, most caregivers report being satisfied with their child's pain management. Caregiver satisfaction is likely multifactorial, and physicians should be careful not to interpret satisfaction as equivalent to adequate provision of analgesia. The relationship between satisfaction and pain merits further exploration.
The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidoca... more The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray. Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip), control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity, Cry and Consolability (FLACC) tool at 3 points; baseline, before approach; device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0 (none) to 10 (severe). Comparisons of pain scores over time were made with the generalized estimating equation. Venipuncture success and adverse effects were assessed and compared with χ(2). Two hundred five children enrolled: intervention 96, control 53, and sham 56. There were no between-group differences in baseline characteristics. There was no mean change in pain scores from device to venipuncture in the intervention group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95% CI 0.83 to 2.52) groups. This change was greater for the control and sham compared to the intervention group. There was no difference in venipuncture success between groups. No severe adverse events occurred. Minor adverse events were the same between groups. Use of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared with vapocoolant spray or sham treatment.
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, Jan 16, 2015
The needle-free jet injection system with buffered lidocaine (J tip) has been shown to reduce pai... more The needle-free jet injection system with buffered lidocaine (J tip) has been shown to reduce pain for intravenous (IV) line insertion, but its relationship with successful IV placement has not been well studied. This study aimed to determine if J tip use is associated with improved first-attempt IV placement success in children. This was a retrospective cohort study of children ages 1 to 18 years with need for emergent IV placement. Approximately 300 children were selected from each of three separate age groups: 1 to 2, 3 to 6, and 7 to 18 years. The standard treatment group (no device) included children with IV insertions from January 2009 through January 2010 with no J tip. The J tip treatment group (device) included children with IV insertions from December 2010 through December 2011 who received J tips. Successful IV placement on first attempt was the primary outcome. A chi-square test was used to compare the proportion of first-attempt success and logistic regression was perfo...
To examine the relationship between pediatric patient visit characteristics and pain score docume... more To examine the relationship between pediatric patient visit characteristics and pain score documentation in the emergency department (ED) and determine whether documentation of a pain score is associated with increased analgesic use. A cross-sectional analysis was conducted of ED visits for pediatric patients from the National Hospital Ambulatory Medical Care Survey (1997-2000). Survey weighted regression first was used to assess the association between patient visit characteristics and pain score documentation. The regression then was repeated to determine the association between documentation of a pain score and analgesic use, adjusting for visit characteristics. A total of 24,707 visits were included. Only 44.5% of visits had documented pain scores. In the regression analysis, younger age, self-pay, visits to pediatric facilities, and visits that were not designated as injury related were associated with decreased pain score documentation. Documentation of pain score was associat...
Given the availability of various pain severity scales, greater understanding of the agreement be... more Given the availability of various pain severity scales, greater understanding of the agreement between pain scales is warranted. We compared Visual Analog Scale (VAS) and Numeric Rating Scale (NRS) pain severity ratings in children with sickle cell disease (SCD) to identify the relationship and agreement between pain scale ratings. Twenty-eight patients (mean±SD age, 14.65±3.12 y, 50% female) receiving pain interventions within the emergency department completed serial VAS and NRS pain severity ratings every 30 minutes. Data were used to calculate the relationship (Spearman correlation) and agreement (Bland-Altman approach) between the VAS and NRS. One hundred twenty-eight paired VAS-NRS measurements were obtained. VAS and NRS ratings were significantly correlated for the initial assessment (rs=0.88, P<0.001) and all assessments (rs=0.87, P<0.001). Differences between VAS and NRS means were -0.52 (P=0.006) for the initial assessment and -0.86 (P<0.001) across all assessments. The difference between VAS and NRS ratings decreased as pain severity increased across all assessments (P=0.027), but not the initial assessment. Within pediatric patients with SCD, VAS and NRS ratings were found to trend together; however, VAS scores were found to be significantly lower than NRS scores across assessments. The agreement between the 2 measures improved at increasing levels of pain severity. These findings demonstrate that the VAS and NRS are similar, but cannot be used interchangeably when assessing self-reported pain in SCD.
ABSTRACTObjective:Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to ... more ABSTRACTObjective:Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to the emergency department (ED). The primary objective of this study was to describe current analgesic administration practices for the outpatient management of children's MSK pain, both in the ED and postdischarge. We reviewed the medical records of consecutive pediatric patients evaluated in either a pediatric or a general ED (Edmonton, Alberta) during four evenly distributed calendar months, with a diagnosis of fracture, dislocation, strain, or sprain of a limb. Abstracted data included demographics, administered analgesics, pain scores, discharge medication advice, and timing of clinical care. A total of 543 medical records were reviewed (n = 468 pediatric ED, n = 75 general ED). Nineteen percent had documented prehospital analgesics, 34% had documented in-ED analgesics, 13% reported procedural sedation, and 24% documented discharge analgesia advice. Of those children receiving...
We explored caregiver perspectives on their children&... more We explored caregiver perspectives on their children's pain management in both a pediatric (PED) and general emergency department (GED). Study objectives were to: (1) measure caregiver estimates of children's pain scores and treatment; (2) determine caregiver level of satisfaction; and (3) determine factors associated with caregiver satisfaction. This prospective survey examined a convenience sample of 97 caregivers (n=51 PED, n=46 GED) with children aged <17 years. A paper-based survey was distributed by research assistants, from 2009-2011. Most caregivers were female (n=77, 79%) and were the child's mother (n=69, 71%). Children were treated primarily for musculoskeletal pain (n=41, 42%), headache (n=16, 16%) and abdominal pain (n=7, 7%). Using a 100 mm Visual Analog Scale, the maximum mean reported pain score was 75 mm (95% CI: 70-80) and mean score at discharge was 39 mm (95% CI: 32-46). Ninety percent of caregiver respondents were satisfied (80/89, 90%); three (3/50, 6%) were dissatisfied in the PED and six (6/39, 15%) in the GED. Caregivers who rated their child's pain at ED discharge as severe were less likely to be satisfied than those who rated their child's pain as mild or moderate (p=0.034). Despite continued pain upon discharge, most caregivers report being satisfied with their child's pain management. Caregiver satisfaction is likely multifactorial, and physicians should be careful not to interpret satisfaction as equivalent to adequate provision of analgesia. The relationship between satisfaction and pain merits further exploration.
A 33-y-old male developed severe acidosis, renal failure, and profound neutrophilia after ingesti... more A 33-y-old male developed severe acidosis, renal failure, and profound neutrophilia after ingesting ethylene glycol. Workup for his neutrophilia excluded infectious and malignant causes. An elevated leukocyte alkaline phosphatase (LAP) level confirmed a leukemoid response, and the neutrophila resolved. Although several leukemoid reactions have been published due to therapeutic agents these reports are often incomplete or inaccurate; this is the first case of leukemoid response to a toxin. Leukemoid response is distinguishable from leukemia by the absence of clonally derived cells, although this is not easily apparent in extreme neutrophilia. Elevated LAP is useful in identifying leukemoid reaction from leukemia in cases of extreme neutrophila. If a patient develops extreme neutrophila in association with drug or toxin exposure, a leukemoid reaction should be considered and an LAP obtained.
During childhood, pain often is experienced on a nearly daily basis. This study focuses on pain a... more During childhood, pain often is experienced on a nearly daily basis. This study focuses on pain alleviation techniques provided by parents, because children's painful experiences are most often treated at home. Hypotheses addressed various factors that can influence use of pain alleviation techniques, including parents' level of catastrophizing about their children's pain, children's age, and conversations with health care professionals. A total of 756 parents of children ages 6 to 17 years completed an online survey regarding pain alleviation including use and effectiveness of pharmacological and nonpharmacological techniques, pain catastrophizing, and questions regarding dialogue with health care professionals. Parents with increased pain catastrophizing used more pharmacological techniques, and child self-administration of pain alleviation techniques increased with the child's age. Parents were more likely to have spoken with their health care professional about pharmacological techniques. This study provides information that can help health care professionals initiate conversations regarding treatment options and align recommendations with techniques that parents are likely to use, and it can help health care professionals provide supportive alternative recommendations.
Painful procedures are common in the ED setting and beyond. Although these procedures are often e... more Painful procedures are common in the ED setting and beyond. Although these procedures are often essential to patient management, they can also be distressing for children, parents, and health providers. As such, it is imperative that effective pain and anxiety-minimizing strategies be used consistently in all settings where painful procedures take place for children. This review article aims to provide a summary of several strategies, which are supported by definitive and systematically reviewed evidence, that can be implemented alone or in combination to reduce procedural pain and anxiety for children in the ED and beyond. For neonates, breastfeeding, nonnutritive sucking, swaddling, and sucrose administration have all been shown to decrease pain during painful interventions. For neonates, venipuncture is much less painful than heel lance for blood draws. For infants, there is some support for sucrose use. For infants and older children, there is strong evidence for distraction techniques. In addition, the use of fast-acting topical anesthetic creams as an alternative or adjunct to infiltrating anesthetic before laceration repair or vascular access/venipuncture is recommended. Further, buffering of lidocaine can decrease pain during injection. Lastly, if a laceration is amenable to the use of tissue adhesive, this should be preferentially used. In summary, there currently remains a knowledge-to-practice gap in the treatment of children's procedure-related pain. This article has identified multiple age-specific methods to improve the treatment of procedural pain. These simple interventions can improve the care provided to ill and injured children.
Objective This study aims to determine the frequency that umbilical venous catheters (UVCs) and p... more Objective This study aims to determine the frequency that umbilical venous catheters (UVCs) and peripherally inserted central catheters (PICCs) migrate into the cardiothymic silhouette after initial verification of correct placement. Study Design This is a single-center, retrospective study in neonates in whom a PICC or UVC was placed. The frequency of catheter tip migration into the cardiothymic silhouette requiring catheter manipulation was determined radiographically at 1 and 24 hours, respectively, after insertion. Results At 1 and 24 hours, 36 and 23% of UVCs (n = 41) migrated into the cardiothymic silhouette, respectively. At 1 and 24 hours, 23 and 11% of PICCs (n = 63) migrated into the cardiothymic silhouette, respectively. Migration was not associated with birth weight, weight at insertion, or postnatal age at insertion. Conclusion UVCs and PICCs frequently migrate into the cardiothymic silhouette increase the risk for development of a pericardial effusion. Serial radiographic assessment of catheter tip location is needed to assess catheter migration within the first 24 hours of line placement.
We explored caregiver perspectives on their children&... more We explored caregiver perspectives on their children's pain management in both a pediatric (PED) and general emergency department (GED). Study objectives were to: (1) measure caregiver estimates of children's pain scores and treatment; (2) determine caregiver level of satisfaction; and (3) determine factors associated with caregiver satisfaction. This prospective survey examined a convenience sample of 97 caregivers (n=51 PED, n=46 GED) with children aged <17 years. A paper-based survey was distributed by research assistants, from 2009-2011. Most caregivers were female (n=77, 79%) and were the child's mother (n=69, 71%). Children were treated primarily for musculoskeletal pain (n=41, 42%), headache (n=16, 16%) and abdominal pain (n=7, 7%). Using a 100 mm Visual Analog Scale, the maximum mean reported pain score was 75 mm (95% CI: 70-80) and mean score at discharge was 39 mm (95% CI: 32-46). Ninety percent of caregiver respondents were satisfied (80/89, 90%); three (3/50, 6%) were dissatisfied in the PED and six (6/39, 15%) in the GED. Caregivers who rated their child's pain at ED discharge as severe were less likely to be satisfied than those who rated their child's pain as mild or moderate (p=0.034). Despite continued pain upon discharge, most caregivers report being satisfied with their child's pain management. Caregiver satisfaction is likely multifactorial, and physicians should be careful not to interpret satisfaction as equivalent to adequate provision of analgesia. The relationship between satisfaction and pain merits further exploration.
The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidoca... more The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray. Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip), control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity, Cry and Consolability (FLACC) tool at 3 points; baseline, before approach; device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0 (none) to 10 (severe). Comparisons of pain scores over time were made with the generalized estimating equation. Venipuncture success and adverse effects were assessed and compared with χ(2). Two hundred five children enrolled: intervention 96, control 53, and sham 56. There were no between-group differences in baseline characteristics. There was no mean change in pain scores from device to venipuncture in the intervention group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95% CI 0.83 to 2.52) groups. This change was greater for the control and sham compared to the intervention group. There was no difference in venipuncture success between groups. No severe adverse events occurred. Minor adverse events were the same between groups. Use of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared with vapocoolant spray or sham treatment.
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, Jan 16, 2015
The needle-free jet injection system with buffered lidocaine (J tip) has been shown to reduce pai... more The needle-free jet injection system with buffered lidocaine (J tip) has been shown to reduce pain for intravenous (IV) line insertion, but its relationship with successful IV placement has not been well studied. This study aimed to determine if J tip use is associated with improved first-attempt IV placement success in children. This was a retrospective cohort study of children ages 1 to 18 years with need for emergent IV placement. Approximately 300 children were selected from each of three separate age groups: 1 to 2, 3 to 6, and 7 to 18 years. The standard treatment group (no device) included children with IV insertions from January 2009 through January 2010 with no J tip. The J tip treatment group (device) included children with IV insertions from December 2010 through December 2011 who received J tips. Successful IV placement on first attempt was the primary outcome. A chi-square test was used to compare the proportion of first-attempt success and logistic regression was perfo...
To examine the relationship between pediatric patient visit characteristics and pain score docume... more To examine the relationship between pediatric patient visit characteristics and pain score documentation in the emergency department (ED) and determine whether documentation of a pain score is associated with increased analgesic use. A cross-sectional analysis was conducted of ED visits for pediatric patients from the National Hospital Ambulatory Medical Care Survey (1997-2000). Survey weighted regression first was used to assess the association between patient visit characteristics and pain score documentation. The regression then was repeated to determine the association between documentation of a pain score and analgesic use, adjusting for visit characteristics. A total of 24,707 visits were included. Only 44.5% of visits had documented pain scores. In the regression analysis, younger age, self-pay, visits to pediatric facilities, and visits that were not designated as injury related were associated with decreased pain score documentation. Documentation of pain score was associat...
Given the availability of various pain severity scales, greater understanding of the agreement be... more Given the availability of various pain severity scales, greater understanding of the agreement between pain scales is warranted. We compared Visual Analog Scale (VAS) and Numeric Rating Scale (NRS) pain severity ratings in children with sickle cell disease (SCD) to identify the relationship and agreement between pain scale ratings. Twenty-eight patients (mean±SD age, 14.65±3.12 y, 50% female) receiving pain interventions within the emergency department completed serial VAS and NRS pain severity ratings every 30 minutes. Data were used to calculate the relationship (Spearman correlation) and agreement (Bland-Altman approach) between the VAS and NRS. One hundred twenty-eight paired VAS-NRS measurements were obtained. VAS and NRS ratings were significantly correlated for the initial assessment (rs=0.88, P<0.001) and all assessments (rs=0.87, P<0.001). Differences between VAS and NRS means were -0.52 (P=0.006) for the initial assessment and -0.86 (P<0.001) across all assessments. The difference between VAS and NRS ratings decreased as pain severity increased across all assessments (P=0.027), but not the initial assessment. Within pediatric patients with SCD, VAS and NRS ratings were found to trend together; however, VAS scores were found to be significantly lower than NRS scores across assessments. The agreement between the 2 measures improved at increasing levels of pain severity. These findings demonstrate that the VAS and NRS are similar, but cannot be used interchangeably when assessing self-reported pain in SCD.
ABSTRACTObjective:Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to ... more ABSTRACTObjective:Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to the emergency department (ED). The primary objective of this study was to describe current analgesic administration practices for the outpatient management of children's MSK pain, both in the ED and postdischarge. We reviewed the medical records of consecutive pediatric patients evaluated in either a pediatric or a general ED (Edmonton, Alberta) during four evenly distributed calendar months, with a diagnosis of fracture, dislocation, strain, or sprain of a limb. Abstracted data included demographics, administered analgesics, pain scores, discharge medication advice, and timing of clinical care. A total of 543 medical records were reviewed (n = 468 pediatric ED, n = 75 general ED). Nineteen percent had documented prehospital analgesics, 34% had documented in-ED analgesics, 13% reported procedural sedation, and 24% documented discharge analgesia advice. Of those children receiving...
Uploads
Papers by Amy Drendel