Intranasal Fentanyl for On-the-Hill Analgesia by Ski Patrol

What is the Evidence for Using Intranasal Medicine in the Prehospital Setting? A Systematic Review

OBJECTIVES

Intranasal (IN) medications offer a safe non-invasive way to rapidly deliver drugs in situations where intravenous (IV) access and intramuscular (IM) administration is challenging or not feasible. In the prehospital setting, this can be an essential alternative in time critical situations including trauma management, seizures, and agitated patients. However, there is a paucity of evidence summarizing its efficacy in this environment. This systematic review aims to assess the current evidence supporting the use of IN medicine (midazolam, ketamine, fentanyl, morphine, glucagon, and naloxone) in the prehospital setting alone.

METHODS

A systematic literature search (PROSPERO CRD42023440713) of PubMed, Web of Science, OVID Medline, "Cochrane Central Register of Controlled Trials," Cochrane reviews and Embase was performed from inception to June 2023 to identify studies where IN medications were administered to patients in the prehospital setting. All randomized controlled trials, observational cohort studies, case series, and case reports were included. Papers not written in English, review articles, abstracts, and non-published data (including letters to the editor) were excluded. The methodological quality of the included studies was interpreted using the Cochrane risk of bias tool and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. No funding was received.

RESULTS

From 4818 studies, 39 were included (seven for midazolam, five for ketamine, twelve for fentanyl, one for diamorphine, two for glucagon, and twelve for naloxone). A total of 24,097 patients were treated with IN medications across all the studies. There were five moderate quality, four low quality, and thirty very low quality studies. The potential efficacy of IN fentanyl and ketamine was demonstrated consistently throughout the studies with less clear evidence for midazolam, morphine, glucagon, and naloxone. This review was severely limited by the study quality, with most studies demonstrating "high concerns" for bias.

CONCLUSIONS

Prehospital IN medication administration has wide-ranging potential, particularly for administering analgesia. There are likely to be certain populations, for example, pediatrics, that will benefit the most, although conclusions are limited by the quality of evidence currently available. We encourage additional research in this area, particularly with robust prospective double-blind RCTs.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update

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.

Parenteral, Non-Intravenous Analgesia in Acute Traumatic Pain-A Narrative Review Based on a Systematic Literature Search

Traumatic pain is frequently encountered in emergency care and requires immediate analgesia. Unfortunately, most trauma patients report sustained pain upon arrival at and discharge from the Emergency Department. Obtaining intravenous access to administer analgesics can be time-consuming, leading to treatment delay. This review provides an overview of analgesics with both fast onset and parenteral, non-intravenous routes of administration, and also indicates areas where more research is required.

Pain Management with Inhalation of Methoxyflurane Administrated by Non-Medical Ski Patrol: A Quality Assessment Study

INTRODUCTION

Pain management can be challenging, especially in remote locations where first responders are not certified health care personnel. In these settings, traditional intravenous administration of analgesics is not feasible. In this study, we explore the feasibility of using methoxyflurane as a first-line analgesic in ski-related traumas, administered by the ski patrol, acting as the municipality physician's aiding personnel.

METHODS

This is a quality assessment of a project aimed at improving pain management in trauma patients at the largest ski resort in Norway. Members of the ski patrol were trained and delegated administration of methoxyflurane on behalf of the municipality physician. Patients > 18 years with ski-related trauma and pain Numeric Rating Scale (NRS) of 6 or more were included. The patients received inhalational methoxyflurane on site, with continued administration during transport. Data were collected by the ski patrol and entered into a quality register.

RESULTS

In total, 53 patients (18 to 76 years, 32 (60%) males) accepted to be registered. The injuries were fractures in 35 (66%), joint luxation in seven (13%), combination of fracture and luxation in seven (13%), and blunt soft tissue damage in four (8%) cases. Median NRS before administration of methoxyflurane was 8 decreasing to median NRS 5 after 5-10 min. The median NRS reduction of 3 (25-75% percentiles 2-5) was significant, p < 0.001. Patients rated the perceived effect as good in 40 (80%) moderate in nine (18%) and no effect in 1 (2%). Side effects were mild: Six patients (11%) experienced dizziness, one patient (2%) was considered drowsy.

CONCLUSIONS

Methoxyflurane is feasible as a first-line analgesic administered by a non-medical ski patrol in a responsibly organized system. Early pain management with inhalation of methoxyflurane provides good perceived effect with mild adverse events and can be of great value in settings where few alternatives for pain management are available.

Time to Reconsider Analgesia in Mass Casualty Incidents

The provision of analgesia in mass casualty incidents has traditionally been viewed as low-priority and reserved for later stages of care. Poor pain management is commonplace in trauma victims, and inadequate acute pain management can hinder evacuation efforts and may lead to the development of chronic pain and posttraumatic stress disorder. New, safe, and simple methods for administering quality analgesia have proven to be safe and effective in the prehospital setting and, as such, could easily be implemented into mass casualty incident protocols and allow for analgesia at earlier stages in such incidents, thereby improving patient care.

Endogenous opiates and behavior: 2022

This paper is the forty-fifth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2022 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Analgesic agents administered by ambulance personnel to mountain bikers and hikers on trails in Western Australia

Objective

To describe the types of analgesic medications administered to patients who were attended by ambulance on recreational trails while mountain biking or hiking and report on the reduction in pain by these agents.

Methods

This is a retrospective cohort study of patients attended by ambulance (2015-2021) after mountain biking or hiking, on Western Australia (WA) trails. All data were extracted from electronic patient care records created by ambulance personnel who attended the patient. We compared patient and case characteristics between mountain bikers and hikers and the reduction in pain scores achieved by different analgesics.

Results

A total of 717 patients were included. Paramedics reported traumatic aetiology for mountain bikers in 92 % of cases and hikers in 58 % of cases. A pain score out of 10 was recorded for 538 (75 %) patients. The median (inter-quartile range) initial pain score was 6 (2-8) and the median final pain score was 3 (1-5). Around 48 % of these 538 patients reported ≥25 % reduction in their pain score. A reduction of ≥25 % in their pain score was greatest in those patients who received intravenous fentanyl (81 %), followed by patients administered multiple analgesics (72 %) and methoxyflurane only (52 %). Even 37 % of 134 patients who received no analgesia still reported ≥25 % reduction in their pain score by hospital arrival.

Conclusion

Trauma was the most common reason mountain bikers and hikers on trails called an ambulance and a large proportion of these patients were in pain on ambulance arrival. Further work assessing the effectiveness of safe, non-opioid analgesics, additional to methoxyflurane, is needed to ensure non-registered practitioners such as first aid providers and event medical teams can offer suitable safe analgesics to these patients. Additionally, among patients given no pharmacological analgesic agent, almost half still achieved a >25 % reduction in their pain scores which reiterates the importance of non-pharmacological pain reduction strategies.

Oral transmucosal fentanyl citrate analgesia in prehospital trauma care: an observational cohort study

BACKGROUND

Pain is one of the major prehospital symptoms in trauma patients and requires prompt management. Recent studies have reported insufficient analgesia after prehospital treatment in up to 43% of trauma patients, leaving significant room for improvement. Good evidence exists for prehospital use of oral transmucosal fentanyl citrate (OTFC) in the military setting. We hypothesized that the use of OTFC for trauma patients in remote and challenging environment is feasible, efficient, safe, and might be an alternative to nasal and intravenous applications.

METHODS

This observational cohort study examined 177 patients who were treated with oral transmucosal fentanyl citrate by EMS providers in three ski and bike resorts in Switzerland. All EMS providers had previously been trained in administration of the drug and handling of potential adverse events.

RESULTS

OTFC caused a statistically significant and clinically relevant decrease in the level of pain by a median of 3 (IQR 2 to 4) in NRS units (P < 0.0001). Multiple linear regression analysis showed a significant absolute reduction in pain, with no differences in all age groups and between genders. No major adverse events were observed.

CONCLUSIONS

Prehospital administration of OTFC is safe, easy, and efficient for extrication and transport across all age groups, gender, and types of injuries in alpine environments. Side effects were few and mild. This could provide a valuable alternative in trauma patients with severe pain, without the delay of inserting an intravenous line, especially in remote areas, where fast action and easy administration are important.