Review on pharmacological pain management in trauma patients in (pre-hospital) emergency medicine in the Netherlands

Factors influencing nurses' pain assessment and management of road traffic casualties: a qualitative study at a military hospital in Ghana

BACKGROUND

Evidence shows that patients who visit the surgical and trauma emergency units may be discharged with untreated or increased pain levels. This study explored nurses' pain assessment and management approaches at a trauma-surgical emergency unit in Ghana.

METHODS

Seventeen nurses who work in the trauma department participated in this qualitative exploratory descriptive study. In-depth individual interviews were conducted, and the thematic analysis was utilized to identify emerging themes and subthemes.

RESULTS

Three main themes were identified: patient pain indicators, pain management, and institutional factors influencing pain management. The study revealed that nurses rely on verbal expressions, non-verbal cues, physiological changes, and the severity of pain communicated. The findings highlighted staff shortage, inadequate resources, and lack of standardized guidelines as factors affecting pain and management.

CONCLUSIONS

Although the study offers critical new perspectives on nurses' experiences regarding pain related issues at the trauma-surgical emergency units, its small sample size limited its generalizability.

Severe pain management in the emergency department: patient pathway as a new factor associated with IV morphine prescription

Background

Across the world, 25-29% of the population suffer from pain. Pain is the most frequent reason for an emergency department (ED) visit. This symptom is involved in approximately 70% of all ED visits. The effective management of acute pain with adequate analgesia remains a challenge, especially for severe pain. Intravenous (IV) morphine protocols are currently indicated. These protocols are based on patient-reported scores, most often after an immediate evaluation of pain intensity at triage. However, they are not systematically prescribed. This aspect could be explained by the fact that physicians individualize opioid pain management for each patient and each care pathway to determine the best benefit-risk balance. Few data are available regarding bedside organizational factors involved in this phenomenon.

Objective

This study aimed to analyze the organizational factors associated with no IV morphine prescription in a standardized context of opioid management in a tertiary-care ED.

Methods

A 3-month prospective study with a case-control design was conducted in a French university hospital ED. This study focused on factors associated with protocol avoidance despite a visual analog scale (VAS) ≥60 or a numeric rating scale (NRS) ≥6 at triage. Pain components, physician characteristics, patient epidemiologic characteristics, and care pathways were considered. Qualitative variables (percentages) were compared using Fisher's exact test or the chi-squared tests. Student's t-test was used to compare continuous variables. The results were expressed as means with their standard deviation (SD). Factors associated with morphine avoidance were identified by logistic regression.

Results

A total of 204 patients were included in this study. A total of 46 cases (IV morphine) and 158 controls (IV morphine avoidance) were compared (3:1 ratio). Pain patterns and patient's epidemiologic characteristics were not associated with an IV morphine prescription. Regarding NRS intervals, the results suggest a practice disconnected from the patient's initial self-report. IV morphine avoidance was significantly associated with care pathways. A significant difference between the IV morphine group and the IV morphine avoidance group was observed for "self-referral" [adjusted odds ratio (aOR): 5.11, 95% CIs: 2.32-12.18, p < 0.0001] and patients' trajectories (Fisher's exact test; p < 0.0001), suggesting IV morphine avoidance in ambulatory pathways. In addition, "junior physician grade" was associated with IV morphine avoidance (aOR: 2.35, 95% CIs: 1.09-5.25, p = 0.03), but physician gender was not.

Conclusion

This bedside case-control study highlights that IV morphine avoidance in the ED could be associated with ambulatory pathways. It confirms the decreased choice of "NRS-only" IV morphine protocols for all patients, including non-trauma patterns. Modern pain education should propose new tools for pain evaluation that integrate the heterogeneity of ED pathways.

Efficacy of opioids for traumatic pain in the emergency department: a systematic review and Bayesian network meta-analysis

Aim: To systematically assess and rank the efficacy of opioid medications for traumatic pain in the emergency department in terms of pain relief, adverse events and rescue analgesia. Methods: Four databases were systematically searched until 26 September 2022: PubMed, Embase, Cochrane Library, and Web of Science. Outcomes were pain relief, adverse events (dizziness, hypotension, pruritus, sedation), and rescue analgesia. For each outcome, network plots were drawn to exhibit direct and indirect comparisons, and rank probabilities were utilized to rank the efficacy of different opioids. Results: Twenty studies of 3,040 patients were eligible for this network meta-analysis. According to the rank probabilities, the top three analgesic medications for pain relief may be sufentanil (78.29% probability of ranking first), buprenorphine (48.54% probability of ranking second) and fentanyl (53.25% probability of ranking third); buprenorphine (31.20%), fentanyl (20.14%) and sufentanil (21.55%) were least likely to cause dizziness; the top three analgesic medications which were least likely to cause hypotension were buprenorphine (81.64%), morphine (45.02%) and sufentanil (17.27%); butorphanol (40.56%), morphine (41.11%) and fentanyl (14.63%) were least likely to cause pruritus; the top three medications which were least likely to cause sedation were hydrocodone + acetaminophen (97.92%), morphine (61.85%) and butorphanol (55.24%); patients who received oxycodone (83.64%), butorphanol (38.31%) and fentanyl (25.91%) were least likely to need rescue analgesia in sequence. Conclusion: Sufentanil, buprenorphine and fentanyl may be superior to other opioid medications in terms of pain relief and the incidence of dizziness, hypotension and pruritus, which might be selected as opioid analgesics for traumatic pain in the emergency setting.

Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.

Evaluation of pain management in medical transfer of trauma patients by air

OBJECTIVES

With regionalized trauma care, medical transport times can be prolonged, requiring paramedics to manage patient care and symptoms. Our objective was to evaluate pain management during air transport of trauma patients.

METHODS

We conducted a 12-month review of electronic paramedic records from a provincial critical care transport agency. Patients were included if they were ≥18 years old and underwent air transport to a trauma centre, and excluded if they were Glasgow Coma Scale score <14, intubated, or accompanied by a physician or nurse. Demographics, injury description, and transportation parameters were recorded. Outcomes included pain assessment via 11-point numerical rating scale, patterns of analgesia administration, and analgesia-related adverse events. Results were reported as mean ± standard deviation, [range], (percentage).

RESULTS

We included 372 patients: 47.0 years old; 262 males; 361 blunt injuries. Transport duration was 82.4 ± 46.3 minutes. In 232 (62.4%) patients who received analgesia, baseline numerical rating scale was 5.9 ± 2.5. Fentanyl was most commonly administered at 44.3 [25-60] mcg. Numerical rating scale after first analgesia dose decreased by 1.1 [-2-7]. Thereafter, 171 (73.7%) patients received 2.4 [1-18] additional doses. While 44 (23.4%) patients had no change in numerical rating scale after first analgesia dose, subsequent doses resulted in no change in numerical rating scale in over 65% of patients. There were 43 adverse events recorded, with nausea the most commonly reported (39.5%).

CONCLUSIONS

Initial and subsequent dose(s) of analgesic had minimal effect on pain as assessed via numerical rating scale, likely due in part to inadequate dosing. Future research is required to determine and address the barriers to proper analgesia.

Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations

BACKGROUND

In Europe, healthcare systems and education, as well as the clinical care and health outcomes of patients, varies across countries. Likewise, the management of acute events for patients also differs, dependent on the emergency care setting, e.g. pre-hospital or emergency department. There are various barriers to adequate pain management and factors common to both settings including lack of knowledge and training, reluctance to give opioids, and concerns about drug-seeking behaviour or abuse. There is no single current standard of care for the treatment of pain in an emergency, with management based on severity of pain, injury and local protocols. Changing practices, attitudes and behaviour can be difficult, and improvements and interventions should be developed with barriers to pain management and the needs of the individual emergency setting in mind.

METHODS

With these principles at the forefront, The European Society for Emergency Medicine (EUSEM) launched a programme-the European Pain Initiative (EPI)-with the aim of providing information, advice, and guidance on acute pain management in emergency settings.

RESULTS AND CONCLUSIONS

This article provides treatment recommendations from recently developed guidelines, based on a review of the literature, current practice across Europe and the clinical expertise of the EPI advisors. The recommendations have been developed, evaluated, and refined for both adults and children (aged ≥ 1 year, ≤ 15 years), with the assumption of timely pain assessment and reassessment and the possibility to implement analgesia. To provide flexibility for use across Europe, options are provided for selection of appropriate pharmacological treatment.

Evaluation of Safety and Efficacy of Prehospital Paramedic Administration of Sub-Dissociative Dose of Ketamine in the Treatment of Trauma-Related Pain in Adult Civilian Population

Opiates are addicting and have a high potential for dependency. In the past decades, opiates remained the first-line pharmaceutical option of prehospital treatment for acute traumatic pain in the civilian population. Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that has analgesic properties and may serve as an alternative agent for the treatment of acute traumatic pain in prehospital settings. This study aims to assess the safety and efficacy of ketamine administration by paramedics in civilian prehospital settings for the treatment of acute traumatic pain.

This was a prospective observational study in San Bernardino, Riverside and Stanislaus counties. Patients were included if they were > 15 years of age with complaints of traumatic or burn-related pain. Patients were excluded if they received opiates up to six hours prior to or concurrently with ketamine administration. The dose administered was 0.3 mg/kg intravenously over five minutes with a maximum dose of 30 mg. The option to administer a second dose was available to paramedics if the patient continued to have pain after 15 minutes following the first administration. Paired-T tests were conducted to assess the change in the primary outcome (pain score) and secondary outcomes (e.g. systolic blood pressure, pulse, and respiratory rate). P-value<0.05 was considered to be statistically significant.

A total of 368 patients were included in the final analysis. The average age was 52.9 ± 23.1 years, and the average weight was 80.4 ± 22.2 kg. There was a statistically significant reduction in the pain score (9.13 ± 1.28 vs 3.7 ± 3.4, delta=5.43 ± 3.38, p<0.0001). Additionally, there was a statistically significant change in systolic blood pressure (143.42 ± 27.01 vs 145.65 ± 26.26, delta=2.22 ± 21.1, p=0.044), pulse (88.06 ± 18 vs 84.64 ± 15.92, delta= -3.42 ± 12.12, p<0.0001), and respiratory rate (19.04 ± 3.59 vs 17.74 ± 3.06, delta=-1.3 ± 2.96, p<0.0001).

The current study suggested that paramedics are capable of safely identifying the appropriate patients for the administration of sub-dissociative doses of ketamine in the prehospital setting. Furthermore, the current study suggested that ketamine may be an effective analgesic in a select group of adult trauma patients.

Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative

OBJECTIVES

Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain.

PATIENTS AND METHODS

A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important.

RESULTS

Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%).

CONCLUSION

These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.

Evaluation of the pain intensity differences among hospitalized cancer patients based on a nursing information system

Evaluating the absolute difference in pain intensity and the percentage difference in pain intensity could facilitate an understanding of pain reduction among cancer patients during repeated hospitalizations. Examinations of the absolute differences in pain intensity and the percentage differences in pain intensity according to the worst pain intensity and last evaluated pain intensity before discharge are lacking. The aim of this study was to evaluate the absolute and percentage difference in pain intensities among cancer patients with moderate or severe pain from their 1st to 18th hospitalizations from 2011–2013. A population-based retrospective cohort study was conducted. Pain intensity was assessed using scales and was recorded in a nursing information system. The absolute and percentage difference in pain intensities were examined via the one-sample Kolmogorov-Smirnov test, and group differences in moderate or severe pain were evaluated with the Mann-Whitney U test. For moderate pain patients, the mean absolute difference in pain intensity was 1.52, and the percentage difference in pain intensity was 29.0%; both these values were significant. More significant changes in the absolute and percentage difference in pain intensities were associated with severe pain patients. Both the average absolute difference in pain intensity (3.09) and the percentage difference in pain intensity (38.5%) in patients with severe pain were significantly higher than the average absolute difference in pain intensity (1.52) and the percentage difference in pain intensity (29.0%) in patients with moderate pain. Cancer patients with moderate and severe pain experienced pain reductions of approximately 30% and 40%, respectively. Early pain management intervention in patients with severe pain is necessary to achieve an obvious analgesic effect, and the formula of the percentage difference in pain intensity should be incorporated into the nursing information system to alert clinicians for early detection of the effectiveness of cancer pain management.

Pain is vital in resuscitation in trauma

Implementation of the ATLS algorithm has remarkably improved the resuscitation of trauma patients and has significantly contributed to the systematic management of multi-trauma patients. However, pain remains the most prevalent complaint in trauma patients, and can induce severe complications, further deterioration of health, and death of the patient. Providing appropriate and timely pain management to these patients prompts early healing, reduces stress response, shortens hospital Length of Stay (LOS), diminishes chronic pain, and ultimately reduces morbidity and mortality. Pain has been proposed to be evaluated as the fifth vital sign and be recorded in the vital sign charts in order to emphasize the importance of pain on short- and long-term outcomes of the patients. However, although the quality of pain treatment seems to be improving we believe that pain has been underestimated in trauma. This article aims to provide evidence for the importance of pain in trauma, to support its management in the emergency setting and the acute phase of patients’ resuscitation, and to emphasize on the necessity to introduce the letter P (pain) in the ATLS alphabet.

Intravenous Acetaminophen vs. Ketorolac in Terms of Pain Management in Prehospital Emergency Services: A Randomized Clinical Trial

Introduction:

Although pain management in EDs has been fully addressed in clinical trials, prehospital settings have rarely been investigated.

Objective:

The present study was conducted to compare the effectiveness of intravenous acetaminophen with that of ketorolac in pre-hospital pain control.

Method:

This randomized clinical trial (RCT) was performed at a prehospital setting during EMS missions in Tehran, Iran. The eligible candidates comprised all patients over the age of 7 years with a complaint of moderate to severe pain. The patients were randomly assigned to two groups, one receiving 30 mg of intravenous (IV) ketorolac and the other 1 g of IV acetaminophen. The pain intensity was measured using a visual analog scale (VAS) before administering the analgesic and upon admission to the ED.

Results:

The present study was conducted on 150 patients aged 8–81 years with a mean age of 40.4 ± 17.7, including 84 (56%) males. The mean reduction in the pain score was 14.9±8.6 in the acetaminophen group and 16.0±8.8 in the ketorolac group. Univariate analyses suggested no statistically significant differences between the two groups in terms of delta pain score (pain reduction) (P=0.429).

Conclusion:

Based on the obtained findings, both ketorolac and acetaminophen could be administered for pain management in prehospital settings in both traumatic and non-traumatic patients in case their contraindications are considered.

The effect of pain management in reducing limb and spine radiography in stable traumatic patients admitted to the emergency department

Introduction

Musculoskeletal pain caused by trauma is one of the common complaints of patients referred to the emergency department. Due to the lack of a proper pain control protocol, doctors and nurses do not pay attention to pain, and physicians may tend to request too many radiographs, many of which will be unnecessary. We aimed to study the effect of pain management by fentanyl in reducing the number of radiographs, reducing hospital costs and increasing satisfaction in the patients on patients with isolated trauma in limbs and spine causing musculoskeletal pain.

Patients and methods

A cohort of patients who were referred to the fast-track emergency department with isolated trauma of the upper and lower limbs or spine and triage levels 3, 4 and 5, were visited twice by an emergency medicine resident – before and after application of a pain management protocol using intravenous fentanyl as the principle analgesic. The primary outcome measure was the reduction in the number of radiographs requested; secondary outcomes included alterations in pain levels and patient satisfaction.

Results

A total of 158 patients were included in the study. The median age was 27.5 years, three quarters were male and 20.88% had a positive history of opium addiction. The number and costs of diagnostic radiography significantly decreased after the administration of fentanyl (P < 0.0001), as did pain levels measured on visual analogue scale with a consequent increase in patient satisfaction. There were only six complications resulting from fentanyl administration which were mild and transient. Follow-up after 24–72 h, revealed no missed fractures.

Conclusions

The administration of fentanyl as a strong analgesic as part of an emergency department pain management protocol for trauma patients can be performed with limited minor complications; it can reduce the number of unnecessary X-rays performed, exposure to ionizing radiation and hospital costs as well as improving patient satisfaction without missing fractures.

Retour d’expérience sur l’utilisation du méthoxyflurane aux urgences

L’oligoanalgésie chez le patient traumatisé aux urgences est une situation fréquente du fait de la complexité de la prise en charge de la douleur. L’une des solutions les mieux décrites à ce problème est l’utilisation d’analgésiques dès l’admission du patient. Ce type de protocole est à privilégier notamment en cas de filière de prise en charge rapide au sein des urgences. Le méthoxyflurane est un éther halogéné volatil utilisé en médecine. Son inhalation produit une analgésie supérieure au placebo. Du fait de sa rapidité d’action, de sa facilité d’emploi et de ses propriétés antalgiques, le méthoxyflurane doit faire partie de l’arsenal des thérapeutiques antalgiques aux urgences. Aux urgences du CHU de Grenoble-Alpes, nous privilégions l’utilisation du méthoxyflurane au sein d’un protocole d’analgésie multimodale du patient adulte traumatisé. Dans cette indication, le méthoxyflurane permet d’amorcer l’analgésie et de faire le pont jusqu’à ce que les autres thérapeutiques soient efficaces.

The role of inhaled methoxyflurane in acute pain management

Methoxyflurane is an inhaled analgesic administered via a disposable inhaler which has been used in Australia for over 40 years for the management of pain associated with trauma and for medical procedures in children and adults. Now available in 16 countries worldwide, it is licensed in Europe for moderate to severe pain associated with trauma in conscious adults, although additional applications are being made to widen the range of approved indications. Considering these ongoing developments, we reviewed the available evidence on clinical usage and safety of inhaled analgesic methoxyflurane in trauma pain and in medical procedures in both adults and children. Published data on methoxyflurane in trauma and procedural pain show it to be effective, well tolerated, and highly rated by patients, providing rapid onset of analgesia. Methoxyflurane has a well-established safety profile; adverse events are usually brief and self-limiting, and no clinically significant effects on vital signs or consciousness levels have been reported. Nephrotoxicity previously associated with methoxyflurane at high anesthetic doses is not reported with low analgesic doses. Although two large retrospective comparative studies in the prehospital setting showed inhaled analgesic methoxyflurane to be less effective than intravenous morphine and intranasal fentanyl, this should be balanced against the administration, supervision times, and safety profile of these agents. Given the limitations of currently available analgesic agents in the prehospital and emergency department settings, the ease of use and portability of methoxyflurane combined with its rapid onset of effective pain relief and favorable safety profile make it a useful nonopioid option for pain management. Except for the STOP! study, which formed the basis for approval in trauma pain in Europe, and a few smaller randomized controlled trials (RCTs), much of the available data are observational or retrospective, and further RCTs are currently underway to provide more robust data.

Prehospital ultrasound-guided nerve blocks improve reduction-feasibility of dislocated extremity injuries compared to systemic analgesia. A randomized controlled trial

BACKGROUND

Out-of-hospital analgosedation in trauma patients is challenging for emergency physicians due to associated complications. We compared peripheral nerve block (PNB) with analgosedation (AS) as an analgetic approach for patients with isolated extremity injury, assuming that prehospital required medical interventions (e.g. reduction, splinting of dislocation injury) using PNB are less painful and more feasible compared to AS.

METHODS

Thirty patients (aged 18 or older) were randomized to receive either ultrasound-guided PNB (10 mL prilocaine 1%, 10 mL ropivacaine 0.2%) or analgosedation (midazolam combined with s-ketamine or with fentanyl). Reduction-feasibility was classified (easy, intermediate, impossible) and pain scores were assessed using numeric rating scales (NRS 0-10).

RESULTS

Eighteen patients were included in the PNB-group and twelve in the AS-group; 15 and 9 patients, respectively, suffered dislocation injury. In the PNB-group, reduction was more feasible (easy: 80.0%, impossible: 20.0%) compared to the AS-group (easy: 22.2%, intermediate: 22.2%, impossible: 55.6%; p = 0.01). During medical interventions, 5.6% [1/18] of the PNB-patients and 58.3% [7/12] of the AS-patients experienced pain (p<0.01). Recorded pain scores were significantly lower in the PNB-group during prehospital medical intervention (median[IQR] NRS PNB: 0[0-0]) compared to the AS-group (6[0-8]; p<0.001) as well as on first day post presentation (NRS PNB: 1[0-5], AS: 5[5-7]; p = 0.050). All patients of the PNB-group would recommend their analgesic technique (AS: 50.0%, p<0.01).

CONCLUSIONS

Prehospital ultrasound-guided PNB is rapidly performed in extremity injuries with high success. Compared to the commonly used AS in trauma patients, PNB significantly reduces pain intensity and severity.

Pain management of acute limb trauma patients with intravenous lidocaine in emergency department

INTRODUCTION

This study was designed to assess the possible superiority of intravenous lidocaine to morphine for pain management.

METHODS

This was a randomized double blind controlled superiority trial, carried on in the emergency department (ED). Traumatic patients older than 18-year-old with the complaint of acute pain greater than 4 on a numeric rating scale (NRS) from 0 to 10 on their extremities were eligible. One group received IV lidocaine (1.5 mg/kg), and the other received IV morphine (0.1mg/kg). Pain scores and adverse effects were assessed at 15, 30, 45 and 60 minutes and patients' satisfaction was evaluated two hours later. A minimum pain score reduction of 1.3 from baseline was considered clinically significant.

RESULTS

Fifty patients with the mean age of 31.28±8.7 were enrolled (78% male). The demographic characteristics and pain scores of the two groups was similar. The on-arrival mean pain scores in two groups were, lidocaine: 7.9±1.4 and morphine: 8.0±1.4 (p=0.57) and after 1 hour were, lidocaine: 2.28±1.2 and morphine: 3.2±1.7. Although the pain score decreased significantly in both group (p=0.027), there were not any clinically and statistically significant difference between the two groups (p=0.77). Patients' satisfaction with pain management in both groups were almost similar (p=0.49).

CONCLUSION

The reduction in pain score using IV lidocaine is not superior to IV morphine in adult ED patients with traumatic limb pain.

Exploring Opioid-Sparing Multimodal Analgesia Options in Trauma: A Nursing Perspective

Challenges with opioids (e.g., adverse events, misuse and abuse with long-term administration) have led to a renewed emphasis on opioid-sparing multimodal management of trauma pain. To assess the extent to which currently available evidence supports the efficacy and safety of various nonopioid analgesics and techniques to manage trauma pain, a literature search of recently published references was performed. Additional citations were included on the basis of authors' knowledge of the literature. Effective options for opioid-sparing analgesics include oral and intravenous (IV) acetaminophen; nonsteroidal anti-inflammatory drugs available via multiple routes; and anticonvulsants, which are especially effective for neuropathic pain associated with trauma. Intravenous routes (e.g., IV acetaminophen, IV ketorolac) may be associated with a faster onset of action than oral routes. Additional adjuvants for the treatment of trauma pain are muscle relaxants and alpha-2 adrenergic agonists. Ketamine and regional techniques play an important role in multimodal therapy but require medical and nursing support. Nonpharmacologic treatments (e.g., cryotherapy, distraction techniques, breathing and relaxation, acupuncture) supplement pharmacologic analgesics and can be safe and easy to implement. In conclusion, opioid-sparing multimodal analgesia addresses concerns associated with high doses of opioids, and many pharmacologic and nonpharmacologic options are available to implement this strategy. Nurses play key roles in comprehensive patient assessment; administration of patient-focused, opioid-sparing, multimodal analgesia in trauma; and monitoring for safety concerns.

Effect of light pressure stroking massage with sesame (Sesamum indicum L.) oil on alleviating acute traumatic limbs pain: A triple-blind controlled trial in emergency department

OBJECTIVES

Due to adverse effects of common medications used for traumatic pain management, it is crucial to use complementary methods to alleviate this pain. Present study aimed to assess the effect of light pressure stroking massage with topical sesame oil on pain severity of patients with limbs trauma.

METHODS

This triple-blinded randomized trial was conducted on 40 patients with upper or lower extremities trauma in emergency department of Busheher Amir Al-Momenian Hospital, Busheher, Iran, in 2015-2016. Patients received a 5min massage with either liquid paraffin (placebo) or sesame oil on trauma site twice a day for 9days duration. Pain severity was assessed by visual analogue scale in first day (baseline), 3th, 6th and 9th days of intervention in the both groups.

RESULTS

Mean changes of pain severity between two groups was significant in the 6th (-0.20±1.36; P=0.036) and 9th (-0.36±1.12; P<0.001) days of intervention. Regarding to intake of diclofenac, no significant difference was seen between sesame oil and placebo groups during 9days of intervention (575.23±3.11 and 625.13±4.23 respectively, P=0.601). There were no adverse effects during the study in the both groups.

CONCLUSION

Massage with topical sesame oil was associated with significant reduction in pain severity of patients with limbs trauma. Therefore, it is suggested to use this oil on complementary medicine for pain relief due to low cost, easy usage and lack of adverse effects.

Unité de Coordination Clinique des Services Préhospitaliers d'Urgence: A clinical telemedicine platform that improves prehospital and community health care for rural citizens

Access to health care in Canada's rural areas is a challenge. The Unité de Coordination Clinique des Services Préhospitaliers d'Urgence (UCCSPU) is a telemedicine program designed to improve health care in the Chaudiere-Appalaches and Quebec City regions of Canada. Remote medical services are provided by nurses and by an emergency physician based in a clinical unit at the Alphonse-Desjardins Community Health and Social Services Center. The interventions were developed to meet two objectives. The first is to enhance access to quality health care. To this end, Basic Life Support paramedics and nurses were taught interventions outside of their field of expertise. Prehospital electrocardiograms were used to remotely diagnose ST segment elevation myocardial infarction and to monitor patients who were en route by ambulance to the nearest catheterization facility or emergency department. Basic Life Support paramedics received extended medical authorization that allowed them to provide opioid analgesia via telemedicine physician orders. Nurses from community health centres without physician coverage were able to request medical assistance via a video telemedicine system. The second objective is to optimize medical resources. To this end, remote death certifications were implemented to avoid unnecessary transport of deceased persons to hospitals. This paper presents the telemedicine program and some results.

Using a New Measurement to Evaluate Pain Relief Among Cancer Inpatients with Clinically Significant Pain Based on a Nursing Information System: A Three-Year Hospital-Based Study

OBJECTIVE

Developing a new measurement index is the first step in evaluating pain relief outcomes. Although the percentage difference in pain intensity (%PID) is the most popular indicator, this indicator does not take into account the goal of pain relief. Therefore, the aims of this study were to develop a pain relief index (PRI) for outcome evaluation and to examine the index using demographic characteristics of cancer inpatients with clinically significant pain.

DESIGN

Retrospective cohort study.

SETTING

A national hospital.

SUBJECTS

All cancer inpatients.

METHODS

Pain intensity was assessed using a numerical rating scale, a faces pain scale or the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Tool. Using a nursing information system, a pain score database containing data from 2011 through 2013 was analyzed.

RESULTS

Cancer patients representing 93,812 hospitalizations were considered in this study. We focused on cancer patients for whom the worst pain intensity (WPI) was ≥ 4 points. PRI values of -62.02% to -72.55% were observed in the WPI ≥ 7 and 4 ≤ WPI ≤ 6 groups. Significant (P < 0.05) effects on PRI values were observed among patients who were > 65 years old, those who were admitted to the medicine or gynecology and those who had a hospital stay > 30 days.

CONCLUSION

This hospital-based study demonstrated that the PRI is an effective and valid measure for evaluating outcome data using an electronic nursing information system. We will further define the meaningful range of percentage difference in PRI from various perspectives.

[Prehospital analgesia by paramedics in Rhineland-Palatinate : Feasability, analgesic effectiveness and safety of intravenous paracetamol]

BACKGROUND

In contrast to the widespread practice in life-threatening emergencies, delegation of medical pain therapy to paramedics by the medical director  of Emergency Medical Services, EMS, are still the exception in Germany. This is due to the fact that in non-life-threatening situations, the expected benefit and potential side effects of drug therapy have to be carefully weighed. In addition, in Germany federal law generally restricts the administration of opiates to physicians.

METHODS

In 2011 the medical directors of EMS in the German state of Rhineland- Palatinate (4 million inhabitants) developed and implemented a standard operating procedure (SOP) for paramedics related to the prehospital parenteral administration of paracetamol for patients with isolated limb trauma. After a 2 h training session and examination, paramedics were authorized to administer 1 g of paracetamol to patients with a pain score > 5 points on an 11-point numerical rating scale (NRS). For purposes of quality management, every administration of paracetamol had to be prospectively documented on a specific electronic mission form.

RESULTS

A total of 416 mission forms could be analyzed. After administration of paracetamol the median NRS score decreased from 8 points (interquartile range: 6; 8) to 4 points (interquartile range: 3; 7). In 51.2 % of the patients the pain intensity was reduced by at least 3 NRS points and in 50.5 % of the patients the NRS was less than 5 points after treatment. The extent of pain reduction was positively correlated with the initial NRS value (r = 0.31, p < 0.0001). No serious side effects were noted. The percentage of patients with an initial heart rate > 100/min declined from 14.6 % to 5.2 % after the administration of paracetamol (p < 0.0001), 18.7 % of the patients received paracetamol for trauma not related to the extremities and 7 % of the patients for nontraumatic pain. An emergency physician was involved in 50 % of the EMS missions and 98.6 % of the patients were transported to a hospital for further diagnostics and treatment.

CONCLUSION

The prehospital intravenous administration of paracetamol by paramedics to patients with limb trauma is simple, safe and in 50 % of the patients effective in achieving a NRS value < 5; however, further improvements in prehospital pain therapy initiated by paramedics are desirable, especially in patients with an initial NRS value > 7.

The Effects of Topical Sesame (Sesamum indicum) Oil on Pain Severity and Amount of Received Non-Steroid Anti-Inflammatory Drugs in Patients With Upper or Lower Extremities Trauma

Background:

Most patients with trauma experience different levels of pain. Due to side effects as well as economic burden of drugs used for pain relief after trauma commonly, it is important to use low-cost methods independently or combined with drugs to alleviate pain.

Objectives:

Therefore, this study aimed to investigate the effects of topical sesame oil on pain severity and frequency of received NSAIDs of patients with trauma.

Patients and Methods:

This randomized clinical trial study was conducted on 150 patients with upper or lower extremities trauma in Dezful Ganjavian Hospital, Ahvaz, Iran, in 2014. Data was collected by a researcher-made questionnaire and Visual Analogue Scale (VAS). Patients were divided into two groups of control (n = 75) and intervention (n = 75) randomly. In the intervention group, patients applied topical sesame oil beside the routine cares, while in the control group patients just received routine cares. Severity of pain and frequency of received NSAIDs was assessed in the first, third, seventh and tenth days after the intervention in the both groups. Data was analyzed by SPSS19 software using descriptive and analytic (Chi-square and independent sample t-test) statistical methods.

Results:

Based on student sample t-test, there was a significant difference between intervention and control groups regarding the pain severity in the first (P = 0.06), third (P = 0.001), seventh (P = 0.001) and tenth (P = 0.001) days after the intervention. Besides, the frequency of received NSAIDs in the intervention group and the control group showed significant difference in four days after the intervention (for four days P = 0.001).

Conclusions:

Topical application of sesame oil could reduce pain severity and frequency of received NSAIDs in patients with upper or lower extremities trauma. Therefore, it is recommended to use this oil in complementary medicine for pain relief due to low cost, easy usage and lack of adverse effects.