Analgesie beim Extremitätentrauma durch Rettungsfachpersonal: Daten zu Sicherheit und Wirksamkeit bei präklinischer Morphingabe

Application of analgesics in emergency services in Germany: a survey of the medical directors

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.

Telenotarztsysteme im deutschen Rettungsdienst: eine nationale Sachstandserhebung

Hintergrund und Fragestellung

Bislang liegen nur wenige Daten über den aktuellen Ausbaustand von Telenotarzt(TNA)-Systemen im deutschen Rettungsdienst vor. In einer nationalen Befragung wurde der Sachstand zu Ausbau und Nutzung von TNA-Systemen erhoben.

Material und Methode

Durchführung einer Online-Befragung unter aktiv im deutschen Rettungsdienst tätigen Personen zum Vorhandensein eines TNA-Systems und dessen Ausgestaltung, zu Standardarbeitsanweisungen (SAA) für Rettungsfachpersonal in ausgewählten Einsatzszenarien sowie zu persönlichen Einschätzungen zum Themenkomplex TNA.

Ergebnisse

1023 Teilnehmer aus 77,1 % (n = 299) aller deutschen Rettungsdienstbereiche nahmen teil. 90,3 % (n = 270) der Bereiche hatten kein TNA-System, ein mindestens teilweiser Betrieb war in 9,3 % (n = 29) etabliert. Die Ausgestaltung ist heterogen, die SAA für Rettungsfachpersonal unterscheiden sich auch innerhalb einzelner Bundesländer und zwischen Bereichen mit und ohne TNA erheblich. Regionen mit TNA verfügen zu einem größeren Anteil über SAA und führen einzelne Maßnahmen häufiger durch. So ist eine intravenöse Analgesie durch den Rettungswagen (RTW) bei 0,8 % vs. 8,9 % (n = 1 vs. n = 76) der Teilnehmenden nicht vorgesehen, die Gabe von Acetylsalicylsäure bei akutem Koronarsyndrom ohne ST-Hebung erfolgt in 3,1 % vs. 23,1 % (n = 4 vs. n = 198) nicht. Bei der persönlichen Einschätzung zum Thema TNA besteht ein signifikanter Unterschied zwischen Bereichen mit und ohne vorhandenes TNA-System.

Schlussfolgerungen

Im deutschen Rettungsdienst sind in weniger als einem Zehntel der Bereiche TNA-Systeme in Betrieb und die vorhandenen Systeme sind sehr heterogen gestaltet. Gleiches gilt für das Vorhandensein von Standardarbeitsanweisungen. Dies legt nahe, dass bei nationaler Betrachtung relevante Unterschiede in der notfallmedizinischen Versorgungsqualität der Bevölkerung bestehen.

Graphic abstract

Medikamentengabe durch Notfallsanitäter

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.

[Best practice-example of a paramedic competence system in the context of user and patient safety: the Reutlinger Weg]

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.

[Analgesia for trauma patients in emergency medicine]

Adequate analgesia is one of the most important measures of emergency care in addition to treatment of vital function disorders and, if indicated, should be promptly undertaken; however, a large proportion of emergency patients receive no or only inadequate pain therapy. The numeric rating scale (NRS) is recommended for pain assessment but is not applicable to every group of patients; therefore, vital signs and body language should be included in the assessment. Pain therapy should reduce the NPRS to <5 points. Ketamine and fentanyl, which have an especially rapid onset of action, and also morphine are suitable for analgesia in spontaneously breathing patients. Basic prerequisites for safe and effective analgesia by healthcare professionals are the use of adequate monitoring, the provision of well-defined emergency equipment, and the mastery of emergency procedures. In a structured competence system, paramedics and nursing personnel can perform safe and effective analgesia.

[Development of ground-based physician-staffed emergency missions in the city of Leipzig from 2003 to 2013]

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.

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

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..

Comparison of the Prehospital Trauma Life Support recommendations and the German national guideline on treatment of patients with severe and multiple injuries

BACKGROUND

The Prehospital Trauma Life Support (PHTLS) concept is well established throughout the world. The aim is to improve prehospital care for patients with major trauma. In 2011, a German Level 3 (S3) evidence- and consensus-based guideline on the treatment of patients with severe and multiple injuries was published. The scope of this study was the systematic comparison between the educational content of the worldwide PHTLS concept and the German S3 Guideline.

METHODS

A total of 62 key recommendations of the German S3 Guideline were compared with the content of the English PHTLS manual (eighth edition). Depending on the level of agreement, the recommendations were categorized as (1) agreement, (2) minor variation, or (3) major variation. Comparison was done via a rating system by a number of international experts in the field of out-of-hospital trauma care. The Delphi method was used to get the final statements by indistinct or board-ranged ratings.

RESULTS

Overall, there was no conformity in 12%. In 68% a total agreement and in 88% conformity with slight differences of minor variations were found between the key recommendations of the guideline and the PHTLS manual. The PHTLS primary assessment has a large conformity for the following individual priorities: airway, 92%; breathing, 92%; circulation, 63%; disability, 100%; exposure, 89%.

CONCLUSIONS

According to our comparison, the PHTLS manual is largely compatible with the German S3 Guideline from 2011. The 12% divergent statements concern mainly fluid resuscitation. Minor deviations in the prehospital care are due to a national guideline with an emergency medical service with emergency physicians (S3 Guideline) and a global PHTLS concept.

[Prehospital analgesia by emergency physicians and paramedics : Comparison of effectiveness]

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.

Telemedical support for prehospital Emergency Medical Service (TEMS trial): study protocol for a randomized controlled trial

Background

Increasing numbers of emergency calls, shortages of Emergency Medical Service (EMS), physicians, prolonged emergency response times and regionally different quality of treatment by EMS physicians require improvement of this system. Telemedical solutions have been shown to be beneficial in different emergency projects, focused on specific disease patterns. Our previous pilot studies have shown that the implementation of a holistic prehospital EMS teleconsultation system, between paramedics and experienced tele-EMS physicians, is safe and feasible in different emergency situations. We aim to extend the clinical indications for this teleconsultation system. We hypothesize that the use of a tele-EMS physician is noninferior regarding the occurrence of system-induced patient adverse events and superior regarding secondary outcome parameters, such as the quality of guideline-conforming treatment and documentation, when compared to conventional EMS-physician treatment.

Methods/design

Three thousand and ten patients will be included in this single-center, open-label, randomized controlled, noninferiority trial with two parallel arms. According to the inclusion criteria, all emergency cases involving adult patients who require EMS-physician treatment, excluding life-threatening cases, will be randomly assigned by the EMS dispatching center into two groups. One thousand five hundred and five patients in the control group will be treated by a conventional EMS physician on scene, and 1505 patients in the intervention group will be treated by paramedics who are concurrently instructed by the tele-EMS physicians at the teleconsultation center. The primary outcome measure will include the rate of treatment-specific adverse events in relation to the kind of EMS physician used. The secondary outcome measures will record the specific treatment-associated quality indicators.

Discussion

The evidence underlines the better quality of service using telemedicine networks between medical personnel and medical experts in prehospital emergency care, as well as in other medical areas. The worldwide unique EMS teleconsultation system in Aachen has been optimized and evaluated in pilot studies and subsequently integrated into routine use for a broad spectrum of indications. It has enabled prompt, safe and efficient patient treatment with optimized use of the “resource” EMS physician. There is, however, a lack of evidence as to whether the advantages of the teleconsultation system can be replicated in wider-ranging EMS-physician indications (excluding life-threatening emergency calls).

Trial registration

ClinicalTrials.gov, identifier: NCT02617875. Registered on 24 November 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1781-2) contains supplementary material, which is available to authorized users.

[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.

Prehospital Pain and Analgesic Therapy in Elderly Patients with Hip Fractures

INTRODUCTION

As a part of aging, hip fractures are becoming more common. The connection between increased pain and a poor outcome has previously been shown. Therefore, even in prehospital situations, analgesic therapy appears to be reasonable. We established a prospective study with 153 patients to evaluate the patients' pain levels during the prehospital phase of treatment and prehospital analgesic therapy.

METHODS

We performed a prospective study on 153 patients the age of 60 years or older in a University hospital setting between 2010 and 2011 who suffered hip fracture. Analgesics given and the type of medical staff that was involved were documented. Pain was measured using the NRS upon initial contact of the medical staff and upon admission to our emergency department.

RESULTS

Initial pain level evaluated by EMS (emergency medical service) was 6.8 (SD = 2.7). Twenty-two percent of the patients reported an NRS of 10 as the highest value following their injury. Forty-three of 153 patients (28%) received analgesics. The mean initial pain score for those 43 patients who did receive pain medication was 7.0 (SD = 2.6). However, this score dropped to a mean of 2.8 (SD = 1.4) upon hospital arrival (P < 0.001). The patients who did not receive pain medication had an initial pain score of 4.5 (SD = 1.9). Upon admission to the hospital, this score decreased to a mean of 4.0 (SD = 1.7, P = 0.092).

CONCLUSION

Only a minority of patients with hip fractures received prehospital analgesia. The administration of prehospital analgesia was associated with significant pain relief.

[Practice report: Structured training to improve quality of care in emergency medical service. On-scene supervision: A new approach to emergency medical service training in Wiesbaden and Rheingau-Taunus-Kreis?]

In recent years, the emergency medical services in Wiesbaden and the Rheingau-Taunus district made great efforts to standardise structures. Since there are only few established procedures in the annual examinations for paramedics, there is reason to assume that treatment procedures for patients have not been standardised either. Materials and equipment are not handled uniformly, and employee satisfaction has significantly decreased over the last few years. To solve these problems, all paramedics undergo standardised and structured trainings. These training courses make use of the internationally accepted PHTLS (Pre-Hospital Trauma Life Support) and AMLS (Advanced Life Support Medial) programmes. In addition, practising skills and handling the equipment as well as on-scene supervision is to be established in practical training sessions.