1
|
Fink PB, Wheeler AR, Smith WR, Brant-Zawadzki G, Lieberman JR, McIntosh SE, Van Tilburg C, Wedmore IS, Windsor JS, Hofmeyr R, Weber D. Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update. Wilderness Environ Med 2024; 35:198-218. [PMID: 38651342 DOI: 10.1177/10806032241248422] [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] [Indexed: 04/25/2024]
Abstract
The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.
Collapse
Affiliation(s)
- Patrick B Fink
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Albert R Wheeler
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | - William R Smith
- Department of Emergency Medicine, St. John's Health, Jackson, WY
| | | | | | - Scott E McIntosh
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | | | - Ian S Wedmore
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Ross Hofmeyr
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - David Weber
- Mountain Rescue Collective, LLC, Park City, UT
| |
Collapse
|
2
|
Nguyen T, Mai M, Choudhary A, Gitelman S, Drapkin J, Likourezos A, Kabariti S, Hossain R, Kun K, Gohel A, Niceforo P, Silver M, Motov S. Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine for Treating Acute Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind, Double-Dummy Controlled Trial. Ann Emerg Med 2024:S0196-0644(24)00171-9. [PMID: 38703175 DOI: 10.1016/j.annemergmed.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 05/06/2024]
Abstract
STUDY OBJECTIVE We aimed to assess and compare the analgesic efficacy and adverse effects of intravenous subdissociative-dose ketamine to nebulized ketamine in emergency department (ED) patients with acute painful conditions. METHODS We conducted a prospective, randomized, double-blind, double-dummy clinical trial in adult patients (ages 18 and older) with a numerical rating scale pain score of ≥5. We randomized subjects to receive either a single dose of 0.3 mg/kg of intravenous (IV) ketamine or 0.75 mg/kg of nebulized ketamine through a breath-actuated nebulizer. Primary outcome was the difference in pain scores on the numerical rating scale between groups at 30 minutes postmedication administration. The secondary outcomes included the need for rescue analgesia, occurrences of adverse events in each group, and the difference in pain scores at 15, 30, 60, 90, and 120 minutes. We calculated a 95% confidence interval (CI) for a mean difference at 30 minutes, with a minimum clinically important difference set at 1.3 points. RESULTS We enrolled 150 subjects (75 per group). Mean pain scores through numerical rating scale were 8.2 for both groups at baseline, which decreased to 3.6 and 3.8 at 30 minutes, yielding a mean difference of 0.23 (95% CI -1.32 to 0.857). We observed no clinically concerning changes in vital signs. No serious adverse events occurred in any of the groups throughout the study period. CONCLUSION We found no difference between the administration of IV and nebulized ketamine for the short-term treatment of moderate to severe acute pain in the ED, with both treatments providing a clinically meaningful reduction in pain scores at 30 minutes.
Collapse
Affiliation(s)
- Tommy Nguyen
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Mo Mai
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Amulya Choudhary
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Slavic Gitelman
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Jefferson Drapkin
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY.
| | | | - Sarah Kabariti
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Rukhsana Hossain
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Karina Kun
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, NY
| | - Ankit Gohel
- Department of Pharmacy, Maimonides Medical Center, Brooklyn, NY
| | | | - Michael Silver
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| | - Sergey Motov
- Department of Emergency Medicine Maimonides Medical Center, Brooklyn, NY
| |
Collapse
|
3
|
Scharonow O, Vilcane S, Weilbach C, Scharonow M. Analgesic Therapy with the Opioids Fentanyl and Morphine by Ambulance Personnel in Rural Areas: An Observational Study Over 7 Years. J Pain Res 2024; 17:345-355. [PMID: 38292758 PMCID: PMC10824613 DOI: 10.2147/jpr.s437131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/25/2023] [Indexed: 02/01/2024] Open
Abstract
Background The treatment of severe pain is one of the basic procedures of emergency medicine. In rural regions, longer arrival times of the emergency doctor prevent the earliest possible treatment of pain. Since 2014, a project for independent analgesia by ambulance personnel has been introduced in our ambulance service area. Methods Over a period of 7 years the mission protocols were recorded and statistically evaluated within the framework of an observational study. Among other things, the attendance and transport times, vital signs, pain level, symptom groups (body region) and classification according to disease or accident mechanism were recorded. Treatment data by medication, including dosages, were recorded for fentanyl (monotherapy), morphine (monotherapy) and a combination (change from morphine to fentanyl, additional application of esketamine, metamizole or butylscopolamine). Results In 659 patients, the opioids fentanyl and morphine were used by the ambulance staff, 596 data sets could be evaluated. When an emergency physician was requested, the average time of presence at the scene was 34.8 +- 11.7 min, in cases of unavailability it was 29.0 +-9.8 min (p<0.0001). Analgesic therapy resulted in a reduction of pain from NRS 8.4 (+-1.3) to NRS 3.5 +-1.8 (p<0.0001). Pain intensity after treatment by emergency paramedics compared to emergency physicians was not significantly different with NRS 3.5 +- 1.7 versus NRS 3.6 +-1.9 (p=0.788). Fentanyl was used at a mean dose of 0.18mg +- 0.11 and morphine at a mean dose of 4.4mg +- 3.6mg. There was no clinically relevant decrease in oxygen saturation or respiratory rate in any of the treatment groups. Antagonisation of the opioid effect with naloxone was not necessary in any case. Conclusion Analgesia with morphine and fentanyl by specially trained ambulance personnel according to defined rules of use is a safe and necessary procedure for patients, especially in rural regions.
Collapse
Affiliation(s)
- Olga Scharonow
- Department of Internal Medicine, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany
| | - Signe Vilcane
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany
| | - Christian Weilbach
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany
| | - Maximilian Scharonow
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, St. Josefs-Hospital Cloppenburg (Academic Teaching Hospital of the MHH Hannover), Cloppenburg, Germany
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
The Influence of Gender Bias: Is Pain Management in the Field Affected by Health Care Provider's Gender? Prehosp Disaster Med 2022; 37:638-644. [PMID: 35924723 DOI: 10.1017/s1049023x2200111x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Appropriate pain management indicates the quality of casualty care in trauma. Gender bias in pain management focused so far on the patient. Studies regarding provider gender are scarce and have conflicting results, especially in the military and prehospital settings. STUDY OBJECTIVE The purpose of this study is to investigate the effect of health care providers' gender on pain management approaches among prehospital trauma casualties treated by the Israel Defense Forces (IDF) medical teams. METHODS This retrospective cohort study included all trauma casualties treated by IDF senior providers from 2015-2020. Casualties with a pain score of zero, age under 18 years, or treated with endotracheal intubation were excluded. Groups were divided according to the senior provider's gender: only females, males, or both female and male. A multivariate analysis was performed to assess the odds ratio of receiving an analgesic, depending on the presence of a female senior provider, adjusting for potential confounders. A subgroup analysis was performed for "delta-pain," defined as the difference in pain score during treatment. RESULTS A total of 976 casualties were included, of whom 835 (85.6%) were male. Mean pain scores (SD) for the female only, male only, and both genders providers were 6.4 (SD = 2.9), 6.4 (SD = 3.0), and 6.9 (SD = 2.8), respectively (P = .257). There was no significant difference between females, males, or both female and male groups in analgesic treatment, overall and per specific agent. This remained true also in the multivariate model. Delta-pain difference between groups was also not significant. Less than two-thirds of casualties in this study were treated for pain among all study groups. CONCLUSION This study found no association between IDF Medical Corps providers' gender and pain management in prehospital trauma patients. Further studies regarding disparities in acute pain treatment are advised.
Collapse
|
6
|
Akbas S, Castellucci C, Nehls F, Müller SM, Spahn DR, Kaserer A. [Prehospital Pain Management: Overview and Potential Improvements]. PRAXIS 2022; 111:157-162. [PMID: 35232256 DOI: 10.1024/1661-8157/a003810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Prehospital Pain Management: Overview and Potential Improvements Abstract. Pain is a frequent issue in the prehospital setting. Rapid and adequate analgesia has a positive effect on the physiological and psychological condition of patients. However, up to 43 % of patients still suffer insufficient analgesia. Several studies have identified some factors that contribute to this problem; these factors can be patient- and intervention-specific or dependent on the staff on duty. In order to improve prehospital analgesia in the future, structural and organizational changes as well as the implementation of new methods and therapies are essential.
Collapse
Affiliation(s)
- Samira Akbas
- Institut für Anästhesiologie, Universität Zürich und Universitätsspital Zürich, Zürich
| | - Clara Castellucci
- Institut für Anästhesiologie, Universität Zürich und Universitätsspital Zürich, Zürich
| | - Franziska Nehls
- Institut für Anästhesiologie, Kantonsspital Winterthur, Winterthur
| | - Stefan Matthias Müller
- Schutz & Rettung Zürich, Institut für Anästhesiologie und Intensivmedizin, Stadtspital Triemli, Zürich
| | - Donat R Spahn
- Institut für Anästhesiologie, Universität Zürich und Universitätsspital Zürich, Zürich
| | - Alexander Kaserer
- Institut für Anästhesiologie, Universität Zürich und Universitätsspital Zürich, Zürich
| |
Collapse
|
7
|
Rugg C, Woyke S, Ausserer J, Voelckel W, Paal P, Ströhle M. Analgesia in pediatric trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis. Scand J Trauma Resusc Emerg Med 2021; 29:161. [PMID: 34794486 PMCID: PMC8600762 DOI: 10.1186/s13049-021-00978-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As pediatric patients are typically rare among helicopter emergency medical systems (HEMS), children might be at risk for oligo-analgesia due to the rescuer's lack of experience and the fear of side effects. METHODS In this retrospective analysis, data was obtained from the ÖAMTC HEMS digital database including 14 physician staffed helicopter bases in Austria over a 12-year timeframe. Primary missions involving pediatric trauma patients (< 15 years) not mechanically ventilated on-site were included. Analgesia was assessed and compared between the age groups 0-5, 6-10 and 11-14 years. RESULTS Of all flight missions, 8.2% were dedicated to children < 15 years. Analgetic drugs were administered in 31.4% of all primary missions (3874 of 12,324), wherefrom 2885 were injured and non-ventilated (0-5 yrs.: n = 443; 6-10 yrs.: n = 902; 11-14 yrs.: n = 1540). The majority of these patients (> 75%) suffered moderate to severe pain, justifying immediate analgesia. HEMS physicians typically chose a monotherapy with an opioid (n = 1277; 44.3%) or Esketamine (n = 1187; 41.1%) followed by the combination of both (n = 324; 11.2%). Opioid use increased (37.2% to 63.4%) and Esketamine use decreased (66.1% to 48.3%) in children < 6 vs. > 10 years. Esketamine was more often administered in extremity (57.3%) than in head (41.5%) or spine injuries (32.3%). An intravenous access was less often established in children < 6 years (74.3% vs. 90.8%; p < 0.001). Despite the use of potent analgesics, 396 missions (13.7%) were performed without technical monitoring. Particularly regarding patient data at handover in hospital, merely < 10% of all missions featured complete documentation. Therefore, sufficient evaluation of the efficacy of pain relief was not possible. Yet, by means of respiratory measures required during transport, severe side effects such as respiratory insufficiency, were barely noted. CONCLUSIONS In the physician-staffed HEMS setting, pediatric trauma patients liberally receive opioids and Esketamine for analgesia. With regard to severe respiratory insufficiency during transport, the application of these potent analgesics seems safe.
Collapse
Affiliation(s)
- Christopher Rugg
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Simon Woyke
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Julia Ausserer
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Wolfgang Voelckel
- Department of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr.-Franz-Rehrl-Platz 5, 5010, Salzburg, Austria.,Christophorus Flugrettungsverein, Baumgasse 129, 1030, Vienna, Austria.,Network for Medical Science, University of Stavanger, Stavanger, Norway
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Kajetanerplatz 1, 5010, Salzburg, Austria.,Austrian Society for Mountain and High-Altitude Medicine (ÖGAHM), Lehnrain 30a, 6414, Mieming, Austria
| | - Mathias Ströhle
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria. .,Christophorus Flugrettungsverein, Baumgasse 129, 1030, Vienna, Austria. .,Austrian Society for Mountain and High-Altitude Medicine (ÖGAHM), Lehnrain 30a, 6414, Mieming, Austria.
| |
Collapse
|
8
|
Methoxyflurane in Non-Life-Threatening Traumatic Pain-A Retrospective Observational Study. Healthcare (Basel) 2021; 9:healthcare9101360. [PMID: 34683042 PMCID: PMC8544466 DOI: 10.3390/healthcare9101360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Pain management is a key issue in prehospital trauma. In Switzerland, paramedics have a large panel of analgesic options. Methoxyflurane was recently introduced into Switzerland, and the goal of this study was to describe both the effect of this medication and the satisfaction of its use. This was a retrospective cohort study, performed in one emergency ambulance service. It included adult patients with traumatic pain and a self-assessment of 3 or more on the visual analogue scale or verbal numerical rating scale. The primary outcome was the reduction in pain between the start of the care and the arrival at the hospital. Secondary outcomes included successful analgesia and staff satisfaction. From December 2018 to 4 June to October 2020, 263 patients were included in the study. Most patients had a low prehospital severity score. The median pain at arrival on site was 8 and the overall decrease in pain observed was 4.2 (95% CI 3.9–4.5). Regarding secondary outcomes, almost 60% had a successful analgesia, and over 70% of paramedics felt satisfied. This study shows a reduction in pain, following methoxyflurane, similar to outcomes in other countries, as well as the attainment of a satisfactory level of pain reduction, according to paramedics, with the advantage of including patients in their own care.
Collapse
|
9
|
Imbriaco G, Rondelli R, Maroni F, Mazzolani S, Sasso S, Sebastiani S, Samolsky Dekel BG. Nurse-Administered Analgesic Treatment in Italian Emergency Medical Services: A Nationwide Survey. J Pain Res 2021; 14:1827-1835. [PMID: 34163237 PMCID: PMC8215928 DOI: 10.2147/jpr.s303998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background Acute pain is common among patients requiring assistance from prehospital emergency medical services (EMS). Nonetheless, the undertreatment of pain in this context remains a frequent phenomenon. Timely and effective analgesia is a crucial feature in emergency medicine. To ensure analgesia provision, prehospital paramedics and nurses can administer analgesics via standard operating protocols or under a physician’s remote supervision. Information about such protocols in Italian EMS is lacking. Objective Evaluation of the availability of nurse’s standard analgesia protocols in Italy’s prehospital EMS settings. Methods A cross-sectional online survey involved all 74 Italian emergency medical dispatch centres (EMDCs). Aside from descriptive statistics, we used χ2-analysis and Spearman-rank correlation to look for associations between geographical areas’ dependence upon independent variable categories and their correlations. Results Of all the 74 Italian EMDCs, 70 (94.6%) completed the survey, covering 100 provinces out of a total of 107 (93.5%). Operating nurses’ prehospital analgesia protocols are available in 46 provinces (46.0%). The availability of prehospital analgesia protocols is more extended in northern Italy EMDCs (n=30, 66.7%) than in central Italy (n=9, 42.8%) and southern Italy and islands (n=7, 20.6%). Morphine (76.1% for medical patients and 95.7% for trauma) and paracetamol (89.1% for both) are the most common drugs included in the prehospital analgesia protocols. Conclusion Despite international consensus on the necessity, efficacy, and safety of nurses’ prehospital analgesia provision, nurse-administered analgesia protocols are available in less than half of Italian provinces, with substantial differences between northern, central, and southern areas. These results indirectly indicate potential undertreatment of prehospital pain in Italy and yield practice improvements.
Collapse
Affiliation(s)
- Guglielmo Imbriaco
- Centrale Operativa 118 Emilia Est, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy.,Critical Care Nursing Master Course, University of Bologna, Bologna, Italy
| | - Riccardo Rondelli
- Intensive Care Unit, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Federica Maroni
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,Emergency Department, Bufalini Hospital, Cesena, Italy
| | - Selene Mazzolani
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,Intensive Care Unit, Infermi Hospital, Faenza, Italy
| | - Silvia Sasso
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,Surgical Unit, State Hospital, San Marino, San Marino Republic
| | - Stefano Sebastiani
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Boaz Gedaliahu Samolsky Dekel
- Critical Care Nursing Master Course, University of Bologna, Bologna, Italy.,IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| |
Collapse
|
10
|
Fernandez AR, Bourn SS, Crowe RP, Bronsky ES, Scheppke KA, Antevy P, Myers JB. Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality. Ann Emerg Med 2021; 78:123-131. [PMID: 34112540 DOI: 10.1016/j.annemergmed.2021.02.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVE To describe out-of-hospital ketamine use, patient outcomes, and the potential contribution of ketamine to patient death. METHODS We retrospectively evaluated consecutive occurrences of out-of-hospital ketamine administration from January 1, 2019 to December 31, 2019 reported to the national ESO Data Collaborative (Austin, TX), a consortium of 1,322 emergency medical service agencies distributed throughout the United States. We descriptively assessed indications for ketamine administration, dosing, route, transport disposition, hypoxia, hypercapnia, and mortality. We reviewed cases involving patient death to determine whether ketamine could be excluded as a potential contributing factor. RESULTS Indications for out-of-hospital ketamine administrations in our 11,291 patients were trauma/pain (49%; n=5,575), altered mental status/behavioral indications (34%; n=3,795), cardiovascular/pulmonary indications (13%; n=1,454), seizure (2%; n=248), and other (2%; n=219). The highest median dose was for altered mental status/behavioral indications at 3.7 mg/kg (interquartile range, 2.2 to 4.4 mg/kg). Over 99% of patients (n=11,274) were transported to a hospital. Following ketamine administration, hypoxia and hypercapnia were documented in 8.4% (n=897) and 17.2% (n=1,311) of patients, respectively. Eight on-scene and 120 in-hospital deaths were reviewed. Ketamine could not be excluded as a contributing factor in 2 on-scene deaths, representing 0.02% (95% confidence interval 0.00% to 0.07%) of those who received out-of-hospital ketamine. Among those with in-hospital data, ketamine could not be excluded as a contributing factor in 6 deaths (0.3%; 95% confidence interval 0.1% to 0.7%). CONCLUSION In this large sample, out-of-hospital ketamine was administered for a variety of indications. Patient mortality was rare. Ketamine could not be ruled out as a contributing factor in 8 deaths, representing 0.07% of those who received ketamine.
Collapse
Affiliation(s)
- Antonio R Fernandez
- ESO, Inc, Austin, TX; Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | | | | | - E Stein Bronsky
- Colorado Springs Fire Department, Colorado Springs, CO; El Paso County American Medical Response, Colorado Springs, CO; Plains to Peaks Regional Emergency Trauma Advisory Council, Colorado Springs, CO; El Paso-Teller County 911 Authority, Colorado Springs, CO
| | - Kenneth A Scheppke
- Florida Department of Health, Tallahassee, FL; Palm Beach County Fire Rescue, West Palm Beach, FL
| | - Peter Antevy
- Davie Fire and Rescue, Davie, FL; Coral Springs Fire Department, Coral Springs, FL; Southwest Ranches Fire Rescue, Southwest Ranches, FL
| | | |
Collapse
|
11
|
Rugg C, Woyke S, Voelckel W, Paal P, Ströhle M. Analgesia in adult trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis. Scand J Trauma Resusc Emerg Med 2021; 29:28. [PMID: 33526048 PMCID: PMC7852148 DOI: 10.1186/s13049-021-00839-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/18/2021] [Indexed: 11/14/2022] Open
Abstract
Background Sufficient analgesia is an obligation, but oligoanalgesia (NRS> 3) is frequently observed prehospitally. Potent analgesics may cause severe adverse events. Thus, analgesia in the helicopter emergency medical service (HEMS) setting is challenging. Adequacy, efficacy and administration safety of potent analgesics pertaining to injured patients in HEMS were analysed. Methods Observational study evaluating data from 14 year-round physician-staffed helicopter bases in Austria in a 12-year timeframe. Results Overall, 47,985 (34.3%) patients received analgesics, 26,059 of whom were adult patients, injured and not mechanically ventilated on site. Main drugs administered were opioids (n=20,051; 76.9%), esketamine (n=9082; 34.9%), metamizole (n=798; 3.1%) and NSAIDs (n=483; 1.9%). Monotherapy with opioids or esketamine was the most common regimen (n=21,743; 83.4%), while opioids together with esketamine (n= 3591; 13.8%) or metamizole (n=369; 1.4%) were the most common combinations. Females received opioids less frequently than did males (n=6038; 74.5% vs. n=14,013; 78.1%; p< 0.001). Pain relief was often sufficient (> 95%), but females more often had moderate to severe pain on arrival in hospital (n=34; 5.0% vs. n=59; 3.2%; p=0.043). Administration of potent analgesics was safe, as indicated by MEES, SpO2 and respiratory rates. On 10% of all missions, clinical patient assessment was deemed sufficient by HEMS physicians and monitoring was spared. Conclusions Opioids and esketamine alone or in combination were the analgesics of choice in physician-staffed HEMS in Austria. Analgesia was often sufficient, but females more than males suffered from oligoanalgesia on hospital arrival. Administration safety was high, justifying liberal use of potent analgesics in physician-staffed HEMS. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00839-9.
Collapse
Affiliation(s)
- Christopher Rugg
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Simon Woyke
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Wolfgang Voelckel
- Department of Anaesthesiology and Intensive Care Medicine AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr.-Franz-Rehrl-Platz 5, 5010, Salzburg, Austria
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Kajetanerplatz 1, 5010, Salzburg, Austria.,Austrian Society for Mountain and High-altitude Medicine (ÖGAHM), Lehnrain 30a, 6414, Mieming, Austria
| | - Mathias Ströhle
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria. .,Austrian Society for Mountain and High-altitude Medicine (ÖGAHM), Lehnrain 30a, 6414, Mieming, Austria.
| |
Collapse
|
12
|
Maudet L, Pasquier M, Pantet O, Albrecht R, Carron PN. Prehospital management of burns requiring specialized burn centre evaluation: a single physician-based emergency medical service experience. Scand J Trauma Resusc Emerg Med 2020; 28:84. [PMID: 32819398 PMCID: PMC7439538 DOI: 10.1186/s13049-020-00771-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency medical services regularly encounter severe burns. As standards of care are relatively well-established regarding their hospital management, prehospital care is comparatively poorly defined. The aim of this study was to describe burned patients taken care of by our physician-staffed emergency medical service (PEMS). METHODS All patients directly transported by our PEMS to our burn centre between January 2008 and December 2017 were retrospectively enrolled. We specifically addressed three "burn-related" variables: prehospital and hospital burn size estimations, type and volume of infusion and pain assessment and management. We divided patients into two groups for comparison: TBSA < 20% and ≥ 20%. We a priori defined clinically acceptable limits of agreement in the small and large burn group to be ±5% and ± 10%, respectively. RESULTS We included 86 patients whose median age was 26 years (IQR 12-51). The median prehospital TBSA was 10% (IQR 6-25). The difference between the prehospital and hospital TBSA estimations was outside the limits of agreement at 6.2%. The limits of agreement found in the small and large burn groups were - 5.3, 4.4 and - 10.1, 11, respectively. Crystalloid infusion was reported at a median volume of 0.8 ml/kg/TBSA (IQR 0.3-1.4) during the prehospital phase, which extrapolated over the first 8 h would equal to a median volume of 10.5 ml/kg/TBSA. The median verbal numeric rating scale on scene was 6 (IQR 3-8) and 3 (IQR 2-5) at the hospital (p < 0.001). Systemic analgesia was provided to 61 (71%) patients, predominantly with fentanyl (n = 59; 69%), followed by ketamine (n = 7; 8.1%). The median doses of fentanyl and ketamine were 1.7 mcg/kg (IQR 1-2.6) and 2.1 mg/kg (IQR 0.3-3.2), respectively. CONCLUSIONS We found good agreement in burn size estimations. The quantity of crystalloid infused was higher than the recommended amount, suggesting a potential risk for fluid overload. Most patients benefited from a correct systemic analgesia. These results emphasized the need for dedicated guidelines and decision support aids for the prehospital management of burned patients.
Collapse
Affiliation(s)
- Ludovic Maudet
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, CH-1011, Lausanne, Switzerland.
- Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
- Department of Anesthesiology, Lausanne University Hospital, Ru du Bugnon 46, CH-1011, Lausanne, Switzerland.
| | - Mathieu Pasquier
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, CH-1011, Lausanne, Switzerland
- Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Olivier Pantet
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, CH-1011, Lausanne, Switzerland
- Department of Intensive Care Medicine and Burn Centre, Lausanne University Hospital, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Roland Albrecht
- Rega - Swiss Air-Rescue, Rega Centre, PO Box 1414, CH-8058, Zurich, Switzerland
| | - Pierre-Nicolas Carron
- Faculty of Biology and Medicine, University of Lausanne, Rue du Bugnon 21, CH-1011, Lausanne, Switzerland
- Department of Emergency Medicine, Lausanne University Hospital, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| |
Collapse
|