Use of Immersive Virtual Reality for Laceration Repairs in the Pediatric Emergency Department
Phase: NA
Conditions: Laceration
Sponsor: Eastern Virginia Medical School

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Date: 9.27.2021 
 
 
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Use of Immersive Virtual Reality for Laceration 
Repairs in the Pediatric Emergency Department 
 
 
September 27, 2021 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1.0 Background and Rationale  
 
Small procedures are an everyday occurrence in the pediatric emergency department. Medical 
procedures often elicit anxiety, which amplifies the pain response.i Laceration repair is one of 
the most common procedures performed.  Simple laceration repair can be challenging not from 
a technical standpoint, but due to patient cooperation secondary to patient pain and anxiety.ii 
Usually, uncooperative children squirm, kick, twist, and scream; this is physically challenging 
during a laceration repair. It is the norm for patients to require distraction, analgesia, and 
anxiolytics as well as physical holding in order to achieve adequate patient stillness for safe 
repair. Typical passive distraction methods include watching television, playing on a tablet or 
phone, parental engagement, or Child Life involvement. Distraction is an accessible, low-cost, 
and non-pharmacologic intervention. 
 
Virtual reality is an evolving technology that allows a viewer to be immersed into a simulated 
environment using a head mounted device as well as hand-held controllers. Immersive virtual 
reality is an active form of distraction. Children who actively perform tasks or engage in 
activities forget about their pain and fear.iii Virtual reality has been documented in the 
literature as a safe and effective tool to reduce both pain and anxiety surrounding painful 
procedures in pediatrics as a distraction technique.iv It has also been theorized to diminish pain 
signals during painful procedures.v This technology has been studied in burn scrubs,vi wound 
dressing changes,vii immunizations,viii venipuncture,ix lumbar punctures,x and dental 
proceduresxi in pediatrics. However, virtual reality (VR) has not been well described for 
laceration repair in the pediatric emergency department setting. Side effects might include 
nausea, vomiting, motion sickness, but these have not been proven to be significant outcomes 
in the literature.xii 
 
In our emergency department, the standard of care involves topical 
lidocaine/epinephrine/tetracaine (LET) cream and/or subcutaneous lidocaine, positioning, Child 
Life staff, and distraction. For some children, oral or intranasal anxiolysis is necessary as well as 
physical holding. Our aim for this study is to determine if Virtual Reality goggles can improve 
patient pain and anxiety scores during simple laceration repair when compared to standard 
passive distraction techniques.  
 
2.0 Objectives 
 
The objective of this study is to determine if VR goggles can decrease patient pain and anxiety 
during simple laceration repairs. The primary outcome will be pain scores as assessed by the 
validated Wong Baker Faces Scale and anxiety scores as assessed by the validated Children’s 
Fear Scale. A validated System Usability Scale (SUS) will be measured for each enrolled 
participant that used the VR goggles. Secondary outcomes include time of procedure, use of 
physical holding, adverse outcomes, and pharmacologic interventions.  
 
3.0 Project Procedures 

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This will be a randomized pragmatic study for all patients ages 6-17 years with simple 
lacerations. Simple lacerations will be defined as lacerations within the scope of pediatric 
emergency medicine providers AND not requiring sedation or operative intervention. Subjects 
will be identified by the Emergency Department staff for enrollment. The goal number of 
enrolled participants will be 480, including 240 patients randomized into two groups, 120 per 
group, and 240 parents/guardians. The Emergency Department accepted to participate in this 
study and ED providers will complete the provider’s survey. After signing the consent and 
assent form when appropriate, the patients will be randomized to either receive the standard 
of care or standard or care with immersive virtual reality goggles. Consent and assent will be 
obtained in the patient rooms within the emergency department. The standard of care shall be 
defined to include any of the following: local analgesia (topical LET and/ or subcutaneous 
lidocaine), oral or intranasal midazolam, distraction, Child Life Staff, or physical holding.  
Because each of the aforementioned interventions may vary between patients, it cannot be 
truly standardized; hence, this will be considered a pragmatic study. Patients randomized to the 
VR arm will receive the other standard procedures as well with VR goggles as an adjunct. 
Exclusion criteria include a history of epilepsy, visual or hearing impairment, or intellectual 
disability that would preclude use of VR goggles as determined by the guardian. Additionally, 
any lacerations around the eyes, eyebrows, and nose will be excluded as well as patients 
requiring sedation. Non-English speaking patients will be excluded as well. Hand lacerations will 
not be excluded.   
 
Participants will be identified by ED staff following evaluation of the laceration. The ED staff will 
be given a flowchart with eligibility criteria. All interested participants who meet eligibility 
criteria will be consented. A research team member will obtain consent from parents or 
guardians by providing and reviewing the consent form (see Subject Consent Form). For 
patients who are between 8 and 17 years of age, a research team member will obtain assent by 
providing and reviewing the assent form (see Subject Assent Form). Consent and assent will be 
obtained in the patient’s ED room.    
 
Patients will be separated into groups age 6-11 and 12-17. Patients will be randomized via a 
selection of a sealed envelope which will contain instructions for use of the VR goggles. The 
goggles utilized will be Lenovo Mirage Solo with DayDream, which are standalone VR headset 
with Worldsense Body Tracking. Research staff will coach the child on age-appropriate games, 
as previously determined by Lenovo. 
 
The goggles will be cleansed with Oxivir Tb disinfectant wipes after each use and allowed to dry 
in room air prior to next use. Education will be provided to all ED providers on the proper 
cleansing protocol for the VR goggles (Figure 4). The disinfectant protocol will be available for 
all users during the study, and has been approved by the director of Infection Control at 
Children’s Hospital of the King’s Daughters.  
 
Following the laceration repair, the patient, guardian and health care provider will be surveyed 
(Figure 1, 2, and 3) on paper surveys. The survey includes Likert-type scale questions, binary 

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questions as well as incorporates the Wong Baker Faces Pain Scale and Children’s Fear Scale. 
The duration of the procedure will be recorded by the healthcare provider who completed the 
laceration repair. Time of procedure will be defined as from the time of irrigation to wound 
dressing. Patients and parents will both be filling out their own individual surveys. The parent 
should complete the survey first before the child should the child need assistance with 
completion. Patients and parents may decline to participate in any survey at any time.  
 
The recruitment period will be from November 2021 until February 2021. Enrolled participants 
will not be compensated, and enrollment will be completely voluntary. 
 
4.0 Statistical Analysis  
 
Continuous variables will be presented as mean, standard deviation, median, 25th, and 
75thpercentile. Categorical variables will be presented as frequency and percentage. 
Generalized Linear Model (GLM) will be used to assess the effect of intervention on the 
outcomes of the surveys. The correlation between provider’s, parent’s, patient’s survey will be 
analyzed using the Spearman’s correlation test. All statistical tests will be performed using the R 
software. All statistical tests will be 2-sided and p<0.05 will be considered as statistically 
significant. 
 
5.0 Risks to Participants/ HIPAA Privacy Considerations 
 
No personal identifiers will be recorded as part of the research study. Each enrolled participant 
will be given a unique number for data collection purposes.  The risks involved in the study 
include adverse reactions to the VR goggles, which have been described to rarely cause nausea, 
vomiting, and motion sickness. There is a theoretical infection risk, but the VR goggles will be 
cleaned following a decontamination protocol following each use.  
 
The data will be securely stored in RedCAP without any patient identifiers. The paper surveys 
will be kept in a locked drawer in a locked room within the Pediatric Department of Emergency 
Medicine offices.  
 
 
6.0 Budget 
 
The Virtual Reality goggles are property of the Children’s Hospital of the King’s Daughters Child 
Life department. They will be stored in a locked drawer within the CHKD Emergency 
Department. This project is unfunded.   
 
 
 

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Figure 1. Use of Immersive Virtual Reality for Laceration Repairs in the Pediatric Emergency 
Department  
Patient Survey 
 
 
1. How old are you? 
 
 
 
 
 
___________________ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2. Have you had stitches before? 
 
 
 
 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No 
 
 
 
 
 
 
 
 
 
 
___ Unsure 
 
3. Have you ever used Virtual Reality (VR) goggles before today? 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No 
 
 
 
 
 
 
 
 
 
 
___ Unsure 
 
4. Did you use VR goggles for your stitches today? 
 
 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No  
 
5. Would you use VR goggles again to get stitches? 
 
 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No  
 
 
 
 
6. During your stitches, did you have any of the following (select all that apply)? 
 
 
 
 
 
 
 
___I did not experience any symptoms 
___ Dizziness 
___Headache 
 
 
 
 
 
 
 
___ Nausea 
 
 
 
 
 
 
 
___ Vomiting  
 
 
 
 
 
 
 
___ Other (describe below) 
 
 
 
 
 
 
 
______________________ 
 
 
7. How do you think the stitches went overall?  
 
___ Not well at all 
 
 
 
 
 
 
 
 
 
___ Somewhat not well 
 
 
 
 
 
 
 
 
 
___ Neutral 
 
 
 
 
 
 
 
 
 
___ Somewhat well 
 
 
 
 
 
 
 
 
 
___ Very well  
 
8. The virtual reality goggles made the stitches seem less scary.  
___ Strongly disagree 
___ Disagree 
___ Neutral 
___ Agree 
___ Strongly agree 

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9. How would you rate your pain:  
 
 
 
10. How would you rate how scared you were during the stitches:  
 
Not scary 
A little scary      Somewhat scary 
Very scary 
Super scary 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Figure 2. Use of Immersive Virtual Reality for Laceration Repairs in the Pediatric Emergency 
Department  
Guardian Survey 
 
1. Patient Gender: 
 
 
 
 
 
 
___ Male 
 
 
 
 
 
 
 
 
 
 
___ Female 
 
 
 
 
 
 
 
 
 
 
___ Non-binary 
 
 
 
 
 
 
 
 
 
 
___ Self-identify 
 
 
 
 
 
 
 
 
 
 
___ Prefer not to say 
 
2. What is the patient’s age? 
 
 
 
 
___________________ 
 
 
3. Please indicate if the patient has a developmental disability:  
A. The patient does not have    
     a developmental disability  
B. Autism 
 
 
 
 
 
 
 
C. Cerebral Palsy 
 
 
 
 
 
 
 
D. Intellectual disability 
E. Speech delay 
F. ___________ 
 
 
 
 
 
 
 
 
 
 
 
4. Has the patient had stitches previously? 
 
 
 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No 
 
 
 
 
 
 
 
 
 
 
___ Unsure 
 
5. Has the patient ever used Virtual Reality (VR) goggles before today? 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No 
 
 
 
 
 
 
 
 
 
 
___ Unsure 
 
6. Did the patient use VR goggles for the procedure today? 
 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No  
 
7. If, yes, would you use VR goggles again for this procedure? 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No  
 
 
 
 
 
 
 
 
 
 
___ Did not use today 
 
8. During the procedure did the patient experience any symptoms (select all that apply)? 
 
 
 
 
 
 
___ Did not experience any symptoms 
___ Dizziness 
___ Headache 
 
 
 
 
 
 
 
___ Nausea 
 
 
 
 
 
 
 
___ Vomiting  
 
 
 
 
 
 
 
___ Other (describe below) 

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______________________ 
 
 
 
9. How do you think the procedure went overall? 
 
___ Not well at all  
 
 
 
 
 
 
 
 
 
___ Somewhat not well 
 
 
 
 
 
 
 
 
 
___ Neutral 
 
 
 
 
 
 
 
 
 
___ Somewhat well 
 
 
 
 
 
 
 
 
 
___ Very well   
 
10. In your opinion, did the virtual reality goggles make the procedure seem less scary to the 
patient?  
___ Strongly disagree 
___ Disagree 
___ Neutral 
___ Agree 
___ Strongly agree 
 
 
 
11. How would you rate the patient’s pain:  
 
 
12. How would you rate the patient’s fear:  
 
No fear 
A little fear  
    Some fear          A lot of fear 
The most fear  
 
 

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Figure 3. Use of Immersive Virtual Reality for Laceration Repairs in the Pediatric Emergency 
Department  
Provider Survey 
 
 
 
1. Procedure Duration (from irrigation to closure end):  
 
A. <10 minutes 
B. 10-15 minutes 
C. 16-20 minutes 
D. 21-25 minutes 
E. >25 minutes 
 
2. Did the patient use VR goggles for the procedure today? 
 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No 
 
3. Would you recommend VR goggles again for this procedure? 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No  
 
 
 
4. Did the patient need to be held during the procedure? 
 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No 
 
 
5. Did the patient receive medicine intended to help them stay calm?  
 
___ Yes 
 
 
 
 
 
 
 
 
 
 
___ No 
 
6. During the procedure, did the patient experience any symptoms (select all that apply)? 
 
 
 
 
 
 
___ Did not experience any symptoms 
___ Dizziness 
___ Headache 
 
 
 
 
 
 
 
___ Nausea 
 
 
 
 
 
 
 
___ Vomiting  
 
 
 
 
 
 
 
___ Other (describe below) 
 
 
 
 
 
 
 
______________________ 
 
 
7. How do you think the procedure went overall? 
 
___ Not well at all  
 
 
 
 
 
 
 
 
 
___ Somewhat not well  
 
 
 
 
 
 
 
 
 
___ Neutral 
 
 
 
 
 
 
 
 
 
___ Somewhat well 
 
 
 
 
 
 
 
 
 
___ Very well   
 
8. In your opinion, did the virtual reality goggles make the procedure seem less scary to the 
patient?  

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___ Strongly disagree 
___ Disagree 
___ Neutral 
___ Agree 
___ Strongly agree 
 
 
 
 
 
9. How would you rate the patient’s pain:  
 
 
 
10. How would you rate the patient’s fear:  
 
No fear 
A little fear  
    Some fear          A lot of fear 
The most fear  
 
 
 
 
 

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Figure 4. Education Plan for Disinfection Protocol for Virtual Reality Goggles  
 
1. The company insert for cleansing the virtual reality goggles will be printed, laminated, 
and physically located with the goggles in their carrying case.  
 
2. The protocol for cleaning will be addressed during an Emergency Medicine division 
meeting prior to the start of the project and detailed in the meeting minutes.  
 
3. The protocol will be addressed during a pediatrics monthly resident meeting and 
dispersed in an email from the chief residents.  
 
4. The protocol will be emailed to all rotating residents prior to the start of their rotation.  
 
5. The protocol will also be disseminated to nursing staff and ED techs via Dawn Jennings 
prior to the start of the project.  
 
6. Research project staff will be available either in person or by phone to answer any 
questions regarding the disinfection protocol during the study phase of the project. 
Contact information will be included inside the carrying case for the goggles as well as 
on all written communications (division meeting minutes, chief email, etc. )   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large 
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