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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Pain Management in Children for Broken Bones


Pain management is a hot topic in medicine in general and certainly in medicine for the outdoors. Injuries in particular, and many illnesses, cause pain, which in turn causes the victim to suffer. To a great extent, pain is subjective, but regardless of whether your pain is a "1" or a "10," it can be disabling and even dangerous, particularly if it causes you to be distracted in a situation of risk (e.g., climbing, swimming, walking along a ridgeline).

Broken bones usually hurt a great deal. It's commonly believed that the pain is always of a severity to require the administration of "strong" pain medicine, notably, something containing a narcotic compound. This may not be true. In an article (Annals of Emergency Medicine 2009;54:553-560) entitled "A Randomized Clinical Trial of Ibuprofen Versus Acetaminophen With Codeine for Acute Pediatric Arm Fracture Pain," Amy Drendel, MD and colleagues compared the treatment of pain in children with arm fractures by using ibuprofen in a dose of 10 milligrams per kilogram (2.2 pounds) of body weight versus acetaminophen with codeine in a dose of 1 milligram per kilogram (based on the codeine component of the medication). The children were assessed for three days after discharge from an emergency department. Two hundred forty four patients were analyzed in this study.

The authors concluded that ibuprofen was at least as effective as acetaminophen with codeine for children ages 4 to 18 years with arm fractures treated as outpatients. What is also very interesting is that the children receiving ibuprofen had significantly fewer adverse effects, and both the children and their parents were more satisfied with ibuprofen. The proportion of children who had any function (play, sleep, eating, school) affected by pain was significantly lower for the ibuprofen group.

What to make of all this? The known side medication side effects measured were nausea, vomiting, drowsiness, dizziness, and constipation. Ibuprofen appears to be clearly superior in this study population. This is an eye opener for me, because I am a bit surprised (and now enlightened) by the data. I would have expected these broken bones to require more potent pain medication (e.g., a narcotic), but I see that this is not necessarily the case. In the future, I will recommend ibuprofen (if there is no contraindication) as an initial medication for many more types of pain situations, and wait to see if a more potent "rescue drug" is necessary only as needed, rather than as first choice. If remaining alert and fully functional in an outdoor setting is a priority, this makes double sense.

broken arm image courtesy of

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Tags: Just for Kids

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.