[Acute severe pain in emergencies. The key for efficient analgesia]

Intravenous acetaminophen with morphine versus intravenous morphine alone for acute pain in the emergency room: protocol for a multicenter, randomized, placebo-controlled, double-blinded study (ADAMOPA)

BACKGROUND

In emergency medicine, pain is a frequent reason for consultation. However, there is a great variation in its management which is often insufficient. The use intravenous morphine alone or multimodal analgesia with paracetamol is recommended for severe pain. But robust data are lacking to justify the association of paracetamol with morphine versus morphine alone for pain management in the emergency room (ER). The aim of our study is therefore to assess if in patients with acute pain of moderate to severe intensity with a numerical verbal scale (NVS) ≥5 in the ER, the intravenous administration of morphine alone is not inferior to the administration of intravenous morphine combined with paracetamol at 30 min from the first administration of the study drug.

METHODS

ADAMOPA is a prospective, non-inferiority, multicenter, placebo-controlled, parallel-group, randomized (1:1), double-blind trial. Subjects will be enrolled in the ER if they experience moderate to severe, acute, non-traumatic, and traumatic pain, defined as an NVS ≥5. The primary endpoint will be the between-group difference in mean change in NVS pain scores among patients receiving the combination of intravenous morphine plus paracetamol or intravenous morphine given alone, measured from the time before administration of the study medication to 30 min later.

DISCUSSION

This trial will determine the clinical utility of the association of paracetamol with morphine for pain management in the emergency room. The ADAMOPA trial will be conducted in accordance with the International Council on Harmonization Good Clinical Practices.

TRIAL REGISTRATION

EudraCT number: 2019-002149-39.

CLINICALTRIALS

gov identifier: NCT04148495. Date of trial registration: November 1, 2019.

Factors associated to unrelieved pain in a Morrocan Emergency Department

BACKGROUND

In the light of the impact that pain has on patients, emergency department (ED) physicians need to be well versed in its management, particularly in its acute presentation. The goal of the present study was to evaluate the prevalence of unrelieved acute pain during ED stay in a Moroccan ED, and to identify risk factors of unrelieved pain.

METHODS

Prospective survey of patients admitted to the emergency department of Ibn Sina teaching university hospital in Rabat (Morocco). All patients with acute pain over a period of 10 days, 24 hours each day were included. From each patient, demographic and clinical data, pain characteristics, information concerning pain management, outcomes, and length of stay were collected. Pain intensity was evaluated both on arrival and before discharge using Numerical Rating Scale (NRS). Comparison between patient with relieved and unrelieved pain, and factors associated with unrelieved pain were analyzed using stepwise forward logistic regression.

RESULTS

Among 305 patients who complained of acute pain, we found high levels of intense to severe pain at ED arrival (91.1%). Pain intensity decreased at discharge (46.9%). Unrelieved pain was assessed in 24.3% of cases. Patients with unrelieved pain were frequently accompanied (82.4% vs 67.1%, p = 0.012), and more admitted daily than night (8 am-20 pm: 78.4% vs 64.9%; 21 pm-7 am: 21.6% vs 35.1%, p = 0.031), and complained chiefly of pain less requently (56.8% vs 78.8%, p<0.001). They had progressive pain (73% vs 44.2%, p<0.001), and had a longer duration of pain before ED arrival (72-168 h: 36.5% vs 16.9%; >168 h: 25.5% vs 17.7%, p<0.001). In multivariate analysis, predictor factors of unrelieved pain were: accompanied patients (OR = 2.72, 95% CI = 1.28- 5.76, p = 0.009), pain as chief complaint (OR = 2.32, 95% CI = 1,25-4.31, p = 0.007), cephalic site of pain (OR = 6.28, 95% CI = 2.26-17.46, p<0.001), duration of pain before admission more than 72 hours (72-168 h (OR = 7.85, 95% CI = 3.13-25.30, p = 0.001), and >168 h (OR = 4.55, 95% CI = 1.77-14.90, p = 0.02).

CONCLUSION

This study reported high levels of intense to severe pain at ED arrival. However, one quarter patients felt on discharge from the ED that their pain had not been relieved. The relief of pain in ED depend both sociodemographic, clinical, and pain characteristics factors.

Analgesia in patients with acute abdominal pain

BACKGROUND

For decades, the indication of analgesia in patients with Acute Abdominal Pain (AAP) has been deferred until the definitive diagnosis has been made, for fear of masking symptoms, generating a change in the physical exploration or obstructing the diagnosis of a disease requiring surgical treatment. This strategy has been questioned by some studies that have shown that the use of analgesia in the initial evaluation of patients with AAP leads to a significant reduction in pain without affecting diagnostic accuracy.

OBJECTIVES

To determine whether the evidence available supports the use of opioid analgesics in the diagnostic process of patients with AAP.

SEARCH STRATEGY

Trials were identified through searches in Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library, issue 2, 2009), MEDLINE (1966 to 2009) and EMBASE (1980 to 2009). A randomised controlled trial (RCT) filter for a MEDLINE search was applied (with appropriate modification for an EMBASE search). Trials also were identified through "related articles". The search was not limited by language or publication status.

SELECTION CRITERIA

All published RCTs which included adult patients with AAP, without gender restriction, comparing any opioids analgesia regimen with the non-use of analgesic before any intervention and independent of the results.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the studies identified via the electronic search. Articles that were relevant and pertinent to the aims of the study were selected and their respective full-text versions were collected for subsequent blinded evaluation. The allocation concealment was considered in particular as an option to diminish the biases.The data collected from the studies were reviewed qualitatively and quantitatively using the Cochrane Collaboration statistical software RevMan 5.0. After performing the meta-analysis, the chi-squared test for heterogeneity was applied. In situations of significant clinical heterogeneity, statistical analyses were not applied to the pool of results. In situations of heterogeneity, the random effect model was used to perform the meta-analysis of the results. A sensitivity analysis was also applied based on the evaluation to the methodological quality of the primary studies.

MAIN RESULTS

Eight studies fulfilled the inclusion criteria. Differences with use of opioid analgesia were verified in variables: Change in the intensity of the pain, change in the patients comfort level.

AUTHORS' CONCLUSIONS

The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment.

Prevalence and management of acute pain in prehospital emergency medicine

BACKGROUND

Less is known about the prevalence of pain in prehospital emergency medicine than about pain in the emergency department. Objectives. To estimate the prehospital prevalence of pain and to identify the factors associated with oligoanalgesia.

METHODS

The mobile intensive care units of the emergency services of a Paris suburb conducted this prospective study. All consecutive patients aged 16 years or older who were able to self-assess pain were included around the clock over a period of 11 months in 2007.

RESULTS

Among the 2,279 included patients, 947 had acute pain (42% [95% confidence interval (CI) 40-44]). Pain was intense to severe in 64% of patients. Factors associated with acute pain were trauma (odds ratio [OR] = 2.9 [1.9-4.3]) and age under 75 years (OR = 2.2 [1.7-2.8]). Intense pain was significantly associated with pain of cardiac or traumatic origin. Among the 1,364 patients transported by the mobile units, 48% experienced acute pain (71% had intense to severe pain). An analgesic agent was administered to 73%. According to multivariate analysis, only gynecologic/obstetric emergencies were associated with inadequate treatment (OR = 0.2 [95% CI 0.1-0.6]). Overall, 51% of patients [46-56] experienced pain relief. The rate of pain relief was lowest in patients suffering from trauma or a gynecologic/obstetric disorder.

CONCLUSION

In our studied population, pain in prehospital emergency medicine affects 42% of patients. However, the rate varies widely according to the origin of the pain. Pain management is inadequate, as only one in two patients experiences relief.

Acute pain and availability of analgesia in the prehospital emergency setting in Italy: a problem to be solved

OBJECTIVES

The treatment of acute pain in the prehospital emergency setting remains a significant problem. We evaluated the incidence, site, and possible cause of acute pain in the prehospital period and also the current state of prehospital pain management by evaluating analgesic availability in emergency vehicles in Italy.

METHODS

First aid volunteers documented the presence, intensity, and site of acute pain by questionnaire for over 3 months. Emergency service operations completed a questionnaire on analgesic availability in ambulances and helicopters.

RESULTS

Pain symptoms were present in two-thirds of the patients (n = 383) and ranked as moderate to unbearable in 41.75%. Results of the analgesic availability survey indicate that 10.6% of the ambulance services carry no pain killers (including non-steroidal anti-inflammatory drugs [NSAIDs] and/or paracetamol) and 11.5% are without an opioid. The emergency helicopter survey showed a significant difference in analgesic availability compared with ambulances, with 97.6% having at least one opioid agent available (weak or strong). A wide geographical variation in the availability of analgesic agents in ambulance and helicopter services was seen.

CONCLUSIONS

There is a high prevalence of pain among patients receiving prehospital emergency treatment in Italy and treatment for acute pain during emergency treatment of trauma patients is inadequate. All emergency vehicles, without distinction, should carry opioids and other analgesic drugs (NSAIDs and paracetamol) and there should be no geographic differences in the availability of pain medications.

Analgesia in patients with acute abdominal pain

BACKGROUND

For decades, analgesia for patients with acute abdominal pain was withheld until a definitive diagnosis was established for fear of masking the symptoms, changing physical findings or ultimately delaying diagnosis and treatment of a surgical condition. This non-evidence-based approach has been challenged by recent studies demonstrating that the use of analgesia in the initial evaluation of patients with acute abdominal pain leads to significant pain reduction without affecting diagnostic accuracy. However, early administration of analgesia to such patients can greatly reduce their pain and does not interfere with a diagnosis, which may even be facilitated due to the severity of physical symptoms being reduced.

OBJECTIVES

To determine if the currently available evidence supports the use of opioid analgesia in patient management with acute abdominal pain; and to assess changes in a patient comfort while awaiting definitive diagnosis and final treatment decisions.

SEARCH STRATEGY

Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 4, 2006), MEDLINE (1966 to 2006) and EMBASE (1980 to 2006). Randomized controlled trial filter for MEDLINE and EMBASE search. Trials will also be identified by "related articles". The searches were not limited by language or publication status.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that include adult patients with acute abdominal pain, without gender restriction, comparing any opioid analgesia regime to no analgesia administered prior to any intervention regardless of outcomes.

DATA COLLECTION AND ANALYSIS

Two authors looked independently at the titles and abstracts of reports. Potentially relevant studies selected by at least one reviewer were retrieved in full text versions for potential inclusion. Allocation concealment was important to avoid bias and was graded using the Cochrane approach. The data from studies included was reviewed qualitatively and quantitatively using the Cochrane Collaborations methodology and statistical software RevMan Analysis 1.0.5. In the case of homogeneity or non- worrying heterogeneity, a random effects model was used. Sensitivity analysis was performed based on quality assessment.

MAIN RESULTS

Six studies fulfilled the inclusion criteria. Improvement with use of opioid analgesia was verified in variables patient comfort, reduction of pain, changes in physical examination.

AUTHORS' CONCLUSIONS

The review provide some evidence to support the notion that the use of opioid analgesics in patients with acute abdominal pain is helpful in terms of patient comfort and does not retard decisions to treat.

Presentation, Diagnoses, Mechanisms of Injury, and Treatment of Soldiers Injured in Operation Iraqi Freedom: An Epidemiological Study Conducted at Two Military Pain Management Centers

In recent military conflicts the major source of soldier attrition has not been battle injuries but more mundane causes similar to those encountered in civilian life. In an effort to determine the pain conditions affecting soldiers during wartime, we conducted an observational study among 162 soldiers medically evacuated from Operation Iraqi Freedom who were referred to 2 large pain treatment centers located outside the theaters of combat. Fifty-three percent of soldiers presented with either radicular (n = 49) or axial (n = 37) low back pain, with lumbar herniated disk being the most frequently diagnosed condition (24%). The two most implicated etiologies were exacerbation of a previous pain condition treated with surgery (15%) and motor vehicle accidents(12%). Only 17% of patients were injured during battle. Seventy-two percent of soldiers received at least one nerve block/injection, the most common of which was lumbar epidural steroid administration (22%). Nonsteroidal antiinflammatory drugs were prescribed to 56% of patients, opioids to 49%, and some form of alternative therapy to 17%. Among the 49 patients in whom data were available, only 2% returned to combat duty in Iraq. With the exception of battle-related injuries, the pain conditions suffered during modern warfare seem to be similar to those encountered in civilian pain clinics. To improve the return-to-duty rate, better preventive measures and more aggressive treatment conducted in forward-deployed medical units are recommended.

IMPLICATIONS

We conducted an observational study at two large military pain treatment centers among soldiers injured in Operation Iraqi Freedom. Fifty-three percent of soldiers presented with low back pain, with lumbar herniated disk being the most common diagnosis. Only 2% of patients returned to combat duty in Iraq. To improve the return-to-duty rate, better preventive measures and more aggressive treatment in forward-deployed medical units are recommended.

A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia

STUDY OBJECTIVE

The aim of this study was to compare, by a randomized double-blind method, morphine (M) and fentanyl (F) in a prehospital setting.

METHODS

Consecutive patients with severe, acute pain defined as a visual analog scale score (VASS) of 60/100 or higher were included. The M group received an initial intravenous M injection of 0.1 mg/kg then of 3 mg every 5 minutes. The F group received an initial intravenous F injection of 1 microg/kg then of 30 microg every 5 minutes. The goal of analgesia was a VASS of 30/100 or lower. The end point was the VASS measured 30 minutes after initial administration (VAS [T30]).

RESULTS

There were 26 patients included in the M group and 28 in the F group. Initial VASS(T0) and VASS(T30), mean (95% CI), were 83 (78-88) and 40 (28-52) in the M group and 77 (72-82) and 35 (27-43) in the F group (P=NS). Sixty-two percent of patients in the M group described analgesia as excellent or good vs 76% of those in the F group who did (P=NS). There were no differences in the incidence of side effects in the 2 groups.

CONCLUSION

This study demonstrates that M and F were comparable in treating severe, acute pain in a prehospital setting during the first 30 minutes in spontaneous breathing patients.

Prise en charge de la douleur aiguë sévère chez l’adulte en médecine extrahospitalière : enquête nationale auprès des médecins de Smur

OBJECTIVES

Assessment of skill of physicians staffed Mobile Intensive Care Units (MICU) in severe acute pain (SAP) management.

METHODS

This study was conducted with a phone questionnaire addressed to emergency physicians of all metropolitan Smur (N =360). This questionnaire included medical teaching, professional position, means of severe acute pain assessment and definition of SAP, treatment, analgesic drug availability, locals guidelines and personal assessment of national guidelines were studied.

RESULTS

Exhaustivity was more than 99% (359/360). Eighty percent of physicians were specialized in emergency care, 8% were anaesthesiologists (or intensivists), 78% worked in emergency department and 76% were full time. Forty nine percent of physicians did not know French Society of Anesthesiology and Intensive Care guidelines and 63% did not have locals analgesics guidelines. To define SAP, Visual Analogic Scale (VAS) or Numeric Scale (NS) >6/10 were mentioned only by 17%. Therapeutic efficiency was assessed and defined by VAS or NS <3/10 by 14%. Morphine was available in 90% of MICU, fentanyl in 79% and nalbuphine in 64%. Morphine was used in first intention by 71% of physicians. Guidelines about doses and waiting periods between 2 administrations were followed respectively by 6% and 28%. Ninety percent of physicians combined at least two treatments, 58 % combined at least three and 39%, at least four.

CONCLUSION

This survey showed a low knowledge about severe acute pain management in out-of-hospital setting, both for pain assessment and treatment. There were few locals guidelines to overcome this deficiency. A training work is essential to improve care of acute pain in out-of-hospital setting.

Quality control programme for acute pain management in emergency medicine: a national survey

OBJECTIVE

This national survey was carried out to evaluate the quality programme for acute pain management in the emergency department (ED) and in pre-hospital emergency medical services (EMS).

METHODS

Two types of questionnaires were sent to the chief consultant and the chief nurse of all ED and EMS. Data collected were: the type of structure, quality programme organization, acute pain management, and the training needs to initiate a pain quality programme.

RESULTS

A total of 363 questionnaires were recorded (198 from chief consultants) with 98% of questionnaires being usable. A pain management committee existed in 71% of cases, a quality committee in 83%. A complete quality control procedure existed in 53% of units. An audit on pain management was carried out in only 23% of cases. Training in quality was performed for 64% of physicians and 68% of nurses. Training specifically for pain management was carried out for physicians in 56% of cases and for nurses in 68% of cases. Pain therapeutics protocols existed in 69% of cases. Pain intensity was evaluated 'systematically or often' in 64% at the beginning of patient management, and in 56% at the end of patient management. The staff was 'not very motivated' for a pain management quality programme in less than 3% of responses. A total of 61% of chief consultants and 58% of chief nurses requested advice.

CONCLUSION

Most ED and EMS units seem to master the quality control programme methodology. Units are highly motivated to initiate a quality control programme on pain. Nevertheless, its implementation could benefit from some external support.