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Vilcane S, Scharonow O, Weilbach C, Scharonow M. Application of analgesics in emergency services in Germany: a survey of the medical directors. BMC Emerg Med 2023; 23:104. [PMID: 37710177 PMCID: PMC10500886 DOI: 10.1186/s12873-023-00878-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/31/2023] [Indexed: 09/16/2023] Open
Abstract
ABSTRAC BACKGROUND: Treatment of acute pain is an essential element of pre-hospital care for injured and critically ill patients. Clinical studies indicate the need for improvement in the prehospital analgesia. OBJECTIVE The aim of this study is to assess the current situation in out of hospital pain management in Germany regarding the substances, indications, dosage and the delegation of the use of analgesics to emergency medical service (EMS) staff. MATERIAL AND METHODS A standardized survey of the medical directors of the emergency services (MDES) in Germany was carried out using an online questionnaire. The anonymous results were evaluated using the statistical software SPSS (Chi-squared test, Mann-Whitney-U test). RESULTS Seventy-seven MDES responsible for 989 rescue stations and 397 EMS- physician bases in 15 federal states took part in this survey. Morphine (98.7%), Fentanyl (85.7%), Piritramide (61%), Sufentanil (18.2%) and Nalbuphine (14,3%) are provided as opioid analgesics. The non-opioid analgesics (NOA) including Ketamine/Esketamine (98,7%), Metamizole (88.3%), Paracetamol (66,2%), Ibuprofen (24,7%) and COX-2-inhibitors (7,8%) are most commonly available. The antispasmodic Butylscopolamine is available (81,8%) to most rescue stations. Fentanyl is the most commonly provided opioid analgesic for treatment of a traumatic pain (70.1%) and back pain (46.8%), Morphine for visceral colic-like (33.8%) and non-colic pain (53.2%). In cases of acute coronary syndrome is Morphine (85.7%) the leading analgesic substance. Among the non-opioid analgesics is Ketamine/Esketamine (90.9%) most frequently provided to treat traumatic pain, Metamizole for visceral colic-like (70.1%) and non-colic (68.6%) as well as back pain (41.6%). Butylscopolamine is the second most frequently provided medication after Metamizole for "visceral colic-like pain" (55.8%). EMS staff (with or without a request for presence of the EMS physician on site) are permitted to use the following: Morphine (16.9%), Piritramide (13.0%) and Nalbuphine (10.4%), and of NOAs for (Es)Ketamine (74.1%), Paracetamol (53.3%) and Metamizole (35.1%). The dosages of the most important and commonly provided analgesic substances permitted to independent treatment by the paramedics are often below the recommended range for adults (RDE). The majority of medical directors (78.4%) of the emergency services consider the independent application of analgesics by paramedics sensible. The reason for the relatively rare authorization of opioids for use by paramedics is mainly due to legal (in)certainty (53.2%). CONCLUSION Effective analgesics are available for EMS staff in Germany, the approach to improvement lies in the area of application. For this purpose, the adaptations of the legal framework as well as the creation of a guideline for prehospital analgesia are useful.
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Affiliation(s)
- Signe Vilcane
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
| | - Olga Scharonow
- Department of Internal Medicine, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Cloppenburg, Germany
| | - Christian Weilbach
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
| | - Maximilian Scharonow
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg, Academic Teaching Hospital of the Hannover Medical School (MHH), Krankenhausstrasse, 13, 49661 Cloppenburg, Germany
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Medikamentengabe durch Notfallsanitäter. Notf Rett Med 2022. [DOI: 10.1007/s10049-022-00992-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Hintergrund
Der Bundesverband der Ärztlichen Leiter Rettungsdienst (BV-ÄLRD) hat einen umfangreichen Katalog an Medikamenten für die Anwendung durch Notfallsanitäter vorgeschlagen. Wir evaluierten, wie oft Auszubildende zum Notfallsanitäter diese in ihrer Ausbildung applizierten.
Methode
Wir befragten 71 Auszubildende zum Notfallsanitäter zur Anwendungshäufigkeit 30 verschiedener Medikamente. Die statistische Auswertung erfolgte mit SOFA (Paton-Simpson and Associates Ltd, USA). Die Ergebnisse sind als Mittelwert (Standardabweichung) dargestellt.
Ergebnisse
Adrenalin i.v. wurde 2,22 (6,67) Mal verabreicht. Atropin wurde bei Bradykardie 1,18 (1,97) Mal verabreicht. Benzodiazepine wurden präklinisch 7,27 (10,28) Mal angewendet. Inhalative Betamimetika wurden präklinisch 8,89 (8,06) Mal, Ipratropiumbromid 3,70 (5,91) Mal, Kortikoide 3,79 (5,32) Mal und Antihistaminika 1,82 (4,34) Mal verabreicht. Ondansetron wurde innerklinisch 14,38 (35,06) Mal angewendet. Präklinisch wurde Dimenhydrinat mit 8,14 (10,14) Anwendungen am häufigsten verabreicht. Furosemid wurde präklinisch 6,06 (9,45) Mal verabreicht. Heparin wurde präklinisch 12,00 (14,32) Mal, ASS 14,32 (14,29) Mal und Glyceroltrinitrat 12,25 (10,87) Mal verabreicht. Metamizol wurde präklinisch 8,59 (12,51) Mal, Ketamin 3,51 (5,23) Mal, Opiate/Opioide 10,72 (16,18) Mal und Naloxon 0,20 (0,67) Mal verabreicht. Glukose wurde präklinisch 7,38 (6,67) Mal verabreicht.
Schlussfolgerung
Die Bewertung, für welche Medikamente eine ausreichende Expertise besteht, kann aufgrund fehlender Daten zu Lernkurven oder konsentierter Mindestzahlen nur vor dem Hintergrund klinischer Erfahrung erfolgen. Aus Sicht der Autoren besteht für die meisten untersuchten Medikamente eine ausreichende Expertise.
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Schempf B, Dorau W, Eppler F, Heinemann N, Metzger M, Häske D. [Best practice-example of a paramedic competence system in the context of user and patient safety: the Reutlinger Weg]. Notf Rett Med 2022; 26:1-12. [PMID: 35261560 PMCID: PMC8890017 DOI: 10.1007/s10049-022-00989-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 11/27/2022]
Abstract
The discussion about the competencies and responsibilities of paramedics has been going on for decades and is the subject of controversial legal debates and currently the focus of political attention due to the heterogeneous country-specific design. However, there are only a few published examples of a so-called competency system for the safe and effective use of prehospital emergency medicine interventions. The practical experience of a competence system is presented. Adequate education and training are crucial for development of competence. A physician-supported quality assurance system creates the opportunity to confirm the competencies of paramedics within the framework of competence checks, monitor the system by means of indicators, and detect weak points at an early stage. Safety culture must be exemplified. Standard operating procedures (SOPs) are the guideline for implementation. In a competence system, certified paramedics can be granted authorization and thus contribute to rapid and efficient patient care, while keeping emergency physicians available for indications requiring their competencies.
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Affiliation(s)
- Benjamin Schempf
- DRK Rettungsdienst Reutlingen, Reutlingen, Deutschland
- Medizinische Klinik II – Kardiologie, Angiologie, internistische Intensivmedizin, Klinikum am Steinenberg, Reutlingen, Deutschland
| | | | - Fabian Eppler
- DRK Rettungsdienst Reutlingen, Reutlingen, Deutschland
| | | | | | - David Häske
- DRK Rettungsdienst Reutlingen, Reutlingen, Deutschland
- Zentrum für öffentliches Gesundheitswesen und Versorgungsforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
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[Development of ground-based physician-staffed emergency missions in the city of Leipzig from 2003 to 2013]. Anaesthesist 2017; 67:177-187. [PMID: 29230501 DOI: 10.1007/s00101-017-0393-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 10/10/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The annual number of physician-based emergency missions reported is continuously increasing. Data from large cities concerning this development over long periods is sparse. MATERIAL AND METHODS In this retrospective study the charts of all ground-based physician-staffed emergency missions in the city of Leipzig for the first quarters of 2003 and 2013 were analyzed. Patient characteristics, injury and illness severities, mission location, hospital admission rate, as well as emergency interventions were collated. The emergency mission rate was calculated as rescue missions per 1000 inhabitants per year. RESULTS The number of physician-staffed emergency missions increased by approximately 24% between 2003 and 2013 (6030 vs. 7470, respectively). The emergency mission rate was 48 vs. 58 in the 2 study periods. The median patient age increased from 66 to 70 years. The number of geriatric patients (age ≥ 85 years: n = 650 (11%) vs. n = 1161 (16%), p < 0.01) also increased. The corresponding number of emergency missions in nursing homes showed a fourfold (n = 175, 3% vs. n = 750, 10%, p < 0.01). The percentage of hospital admissions also increased (n = 3049, 51% vs. n = 4738, 66%, p < 0.01). A change in patient distribution to level I hospitals was noticed (n = 1742, 29% vs. n = 3436, 46%, p < 0.01). CONCLUSION The findings suggest that the necessity for the high number of physician-staffed emergency missions should be verified, especially in the context of strained emergency healthcare resources. The basis of an optimized use of resources could be a better inclusion of alternative, especially ambulant, healthcare structures and the implementation of a structured emergency call questionnaire accompanied by a more efficient disposition of the operating resources, not least in view of the economic aspects. Taking the concentrated patient allocation to level 1 hospitals into consideration, there is a need for optimized patient distribution strategies to minimize the overload of individual institutions and thereby improve the general quality of care at the interface between preclinical and clinical emergency medicine.
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Häske D, W. Böttiger B, Bouillon B, Fischer M, Gaier G, Gliwitzky B, Helm M, Hilbert-Carius P, Hossfeld B, Meisner C, Schempf B, Wafaisade A, Bernhard M. Analgesia in Patients with Trauma in Emergency Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2017; 114:785-792. [PMID: 29229039 PMCID: PMC5730701 DOI: 10.3238/arztebl.2017.0785] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 11/29/2016] [Accepted: 07/03/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Suitable analgesic drugs and techniques are needed for the acute care of the approximately 18 200-18 400 seriously injured patients in Germany each year. METHODS This systematic review and meta-analysis of analgesia in trauma patients was carried out on the basis of randomized, controlled trials and observational studies. A systematic search of the literature over the 10-year period ending in February 2016 was carried out in the PubMed, Google Scholar, and Springer Link Library databases. Some of the considered trials and studies were included in a meta-analysis. Mean differences (MD) of pain reduction or pain outcome as measured on the Numeric Rating Scale were taken as a summarizing measure of treatment efficacy. RESULTS Out of 685 studies, 41 studies were considered and 10 studies were included in the meta-analysis. Among the drugs and drug combinations studied, none was clearly superior to another with respect to pain relief. Neither fentanyl versus morphine (MD -0.10 with a 95% confidence interval of [-0.58; 0.39], p = 0.70) nor ketamine versus morphine (MD -1.27 [-3.71; 1.16], p = 0.31), or the combination of ketamine and morphine versus morphine alone (MD -1.23 [-2.29; -0.18], p = 0.02) showed clear superiority regarding analgesia. CONCLUSION Ketamine, fentanyl, and morphine are suitable for analgesia in spontaneously breathing trauma patients. Fentanyl and ketamine have a rapid onset of action and a strong analgesic effect. Our quantitative meta-analysis revealed no evidence for the superiority of any of the three substances over the others. Suitable monitoring equipment, and expertise in emergency procedures are prerequisites for safe and effective analgesia by healthcare professionals..
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Affiliation(s)
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne
| | - Bertil Bouillon
- Department of Orthopedics, Trauma Surgery, and Sports Injuries, Cologne Hospitals, University of Witten/Herdecke
| | - Matthias Fischer
- Department of Anesthesiology, Surgical Intensive Care, Emergency Medicine, and Pain Therapy, Hospital am Eichert, ALB FILS Hospitals, Göppingen
| | - Gernot Gaier
- Department of Anesthesiology and Surgical Intensive Care, Hospital am Steinenberg, Reutlingen
| | | | - Matthias Helm
- Department of Anaesthesiology and Intensive Care Medicine, Section Emergency Medicine, Federal Armed Forces Hospital, Ulm, Germany
| | - Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care, and Emergency Medicine, Bergmannstrost BG Hospital, Halle
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Section Emergency Medicine, Federal Armed Forces Hospital, Ulm, Germany
| | - Christoph Meisner
- Institute for Clinical Epidemiology and Applied Biometrics, University of Tübingen
| | - Benjamin Schempf
- Department of Medicine II – Cardiology, Angiology, Intensive Care, Hospital am Steinenberg, Reutlingen
| | - Arasch Wafaisade
- Department of Orthopedics, Trauma Surgery, and Sports Injuries, Cologne Hospitals, University of Witten/Herdecke
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Schempf B, Casu S, Häske D. [Prehospital analgesia by emergency physicians and paramedics : Comparison of effectiveness]. Anaesthesist 2017; 66:325-332. [PMID: 28258297 DOI: 10.1007/s00101-017-0288-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/30/2016] [Accepted: 02/09/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND In some German emergency medical service districts, analgesia is performed by paramedics without support of emergency physicians on scene. With regard to safety and effectiveness, paramedics should not be overshadowed by emergency physicians. OBJECTIVES Is prehospital analgesia performed by paramedics under medical supervision or emergency physicians comparable regarding processes and effectiveness in the case of isolated limb injury? MATERIAL AND METHODS As a retrospective analysis of patients with isolated limb injury, analgesia performed by paramedics and by emergency physicians was analyzed. In addition to pain reduction, prescribed monitoring, and further airway maneuvers, vital parameters (Glasgow coma scale, systolic blood pressure, heartrate and respiratory rate, oxygen saturation) were recorded at the beginning and end of prehospital treatment. RESULTS Pain was reduced from NRS 8 ± 1 to NRS 2 ± 1 in the paramedic group, and from NRS 8 ± 2 to NRS 2 ± 2 in the physician group, so the mean pain reduction was 6 ± 2 in the paramedic-group and 5 ± 2 in the physician group (p < 0.001). Adequate analgesia was found in 96.9% in the physician group and 91.7% in the paramedic group (p = 0.113). ECG monitoring and oxygen administration according to SOP was significantly more frequent in the paramedic group than in the physician group (p < 0.001). Respiratory frequency was significantly more frequent in the physician group than in the paramedic group (p < 0.001). CONCLUSIONS The study shows, with a given indication, that German paramedics can independently perform safe and successful analgesia under medical supervision.
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Affiliation(s)
- B Schempf
- LNA-Gruppe Kreis Reutlingen, Reutlingen, Deutschland. .,Medizinische Klinik II - Kardiologie, Angiologie, internistische Intensivmedizin, Klinikum am Steinenberg, Steinenbergstraße 31, 72764, Reutlingen, Deutschland.
| | - S Casu
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Kliniken des Main-Taunus-Kreises GmbH, Bad Soden, Deutschland
| | - D Häske
- DRK Rettungsdienst Reutlingen, Reutlingen, Deutschland.,Medizinische Fakultät, Eberhard Karls Universität Tübingen, Tübingen, Deutschland
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Flake F, Gliwitzky B, Grusnick HM, König M, Beckers S. Notfallsanitäter – Chancen und Perspektiven des neuen Berufsbildes. Notf Rett Med 2013. [DOI: 10.1007/s10049-013-1735-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Aniset L, Wulf H, Wranze E, Kill C. Medizinische Leitungsfunktionen im deutschen Rettungsdienst. Notf Rett Med 2011. [DOI: 10.1007/s10049-010-1407-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Verabreichung von Betäubungsmitteln durch Rettungsfachpersonal. Notf Rett Med 2011. [DOI: 10.1007/s10049-011-1471-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Skorning M, Bergrath S, Brokmann J, Rörtgen D, Beckers S, Rossaint R. Stellenwert und Potenzial der Telemedizin im Rettungsdienst. Notf Rett Med 2011. [DOI: 10.1007/s10049-010-1397-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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