Procedural Sedation and Analgesia in Trauma Patients in an Out-of-Hospital Emergency Setting: A Prospective Multicenter Observational Study

Procedural sedation by advanced practice providers in the emergency medical service in the Netherlands: a retrospective study

BACKGROUND

Procedural sedation and analgesia (PSA) is a technique of administering sedatives to induce a state that allows the patient to tolerate painful procedures while maintaining cardiorespiratory function, a condition that is frequently desired prehospital. Non-physician prehospital clinicians often have a limited scope of practice when it comes to providing analgesia and sedation; sometimes resulting in a crew request for back-up from physician-staffed prehospital services.". This is also the case if sedation is desirable. Advanced practice providers (APPs), who are legally authorized and trained to carry out this procedure, may be a solution when the physician-staffed service is not available or will not be available in time.

METHODS

The aim of this study is to gain insight in the circumstances in which an APP, working at the Dutch ambulance service "RAV Brabant MWN" from January 2019 to December 2022, uses propofol for PSA or to provide sedation. With this a retrospective observational document study we describe the characteristics of patients and ambulance runs and evaluates the interventions in terms of safety.

RESULTS

During the study period, the APPs administered propofol 157 times for 135 PSA and in 22 cases for providing sedation. The most common indication was musculoskeletal trauma such as fracture care or the reduction of joint dislocation. In 91% of the situations where propofol was used, the predetermined goal e.g. alignment of fractured extremity, repositioning of luxated joint or providing sedation the goal was achieved. There were 12 cases in which one or more adverse events were documented and all were successfully resolved by the APP. There were no cases of laryngospam, airway obstruction, nor anaphylaxis. None of the adverse events led to unexpected hospitalization or death.

CONCLUSION

During the study period, the APPs performed 135 PSAs and provided 22 sedations. The success rate of predetermined goals was higher than that stated in the literature. Although there were a number of side effects, their incidences were lower than those reported in the literature, and these were resolved by the APP during the episode of care. Applying a PSA by an APP at the EMS "RAV Brabant MWN" appears to be safe with a high success rate.

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study

Background

Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria.

Methods

Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients.

Results

Median numeric pain rating was 8.0 (7.0–8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed.

Conclusion

In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

How safe is prehospital care? A systematic review

Background

As compared to other domains of healthcare, little is known about patient safety incidents (PSIs) in prehospital care. The aims of our systematic review were to identify how the prevalence and level of harm associated with PSIs in prehospital care are assessed; the frequency of PSIs in prehospital care; and the harm associated with PSIs in prehospital care.

Method

Searches were conducted of Medline, Web of Science, PsycInfo, CINAHL, Academic Search Complete and the grey literature. Reference lists of included studies and existing related reviews were also screened. English-language, peer-reviewed studies reporting data on number/frequency of PSIs and/or harm associated with PSIs were included. Two researchers independently extracted data from the studies and carried out a critical appraisal using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD).

Results

Of the 22 included papers, 16 (73%) used data from record reviews, and 6 (27%) from incident reports. The frequency of PSIs in prehospital care was found to be a median of 5.9 per 100 records/transports/patients. A higher prevalence of PSIs was identified within studies that used record review data (9.9 per 100 records/transports/patients) as compared to incident reports (0.3 per records/transports/patients). Across the studies that reported harm, a median of 15.6% of PSIs were found to result in harm. Studies that utilized record review data reported that a median of 6.5% of the PSIs resulted in harm. For data from incident reporting systems, a median of 54.6% of incidents were associated with harm. The mean QATSDD score was 25.6 (SD = 4.1, range = 16–34).

Conclusions

This systematic review gives direction as to how to advance methods for identifying PSIs in prehospital care and assessing the extent to which patients are harmed.

[Volatile anesthetics for prehospital analgesia by paramedics-An overview]

Treatment of acute pain is a central task in emergency medicine. Yet, prehospital pain relief is often insufficient or delayed since the administration of potent intravenous analgesic drugs (such as opioids) is mostly limited to physicians due to legal restrictions or training deficiencies in Germany and Austria. Frequently, prehospitally operating emergency physicians have to be demanded later for anguished patients limiting disposability of physicians for patients who are in a potentially life-threatening condition. Thus, inhaled analgesics could represent an interesting alternative.A mixture of 50% nitrous oxide and 50% oxygen (N₂O, Livopan®) has been available in Germany and Austria for several years; however, prehospital use of Livopan has been merely realized and only one trial has been published. In addition, methoxyflurane (Penthrop®), a volatile anesthetic from the group of the dialkyl esters (2-dichloro-1:1-difluoroethyl-methyl-ester) was approved for the treatment of moderate to severe pain following trauma in adults in many European countries in recent years and was brought onto the market in Austria in 2018. Several in-hospital trials demonstrated high effectiveness in this setting.This article discusses the effects and prehospital areas of application of both substances in the light of the existing literature. We provide a narrative overview of the current study situation and report on a recently performed prehospital application study of methoxyflurane (Penthrop®) from Austria.The need for pressurized gas cylinders for the use of N₂O represents a certain limitation in prehospital use. Furthermore, in certain injuries such as of the inner ear or a pneumothorax N₂O should not be used and the risk of diffusion hypoxemia has to be addressed. Users should be particularly careful and limit the use in alcohol addicts and vegans. The advances of N₂O are that it is odorless, has a fast onset of action, the usability in patients over 1 month old and has stabilizing effects on the circulation. Plenty of literature regarding prehospital as well as in-hospital use of nitrous oxide in emergency, obstetric and pediatric settings show its effectiveness as a single drug as well as in combination with other analgesics, such as paracetamol or various opioids. Its long tradition in Anglo-American countries is also based on its safety and low rate of side effects.Methoxyflurane is easier to store and handle and may be slightly more effective in severe pain after trauma; however, its approval is restricted to adults, where it works significantly better with increasing age, based on the declining minimal alveolar concentration (MAC) of all inhaled anesthetics with increasing age. Furthermore, decades of use of inhaled methoxyflurane in Australia have shown the drug is effective, safe and low in side effects and has a broad spectrum of applications. The use of methoxyflurane is limited in patients with severe hepatic or renal insufficiency and the characteristic odor has been described as unpleasant by some patients. In Europe, three large in-hospital trials showed strong pain relief in trauma patients, even comparable to opioids.Overall, based on the current evidence, the use of nitrous oxide and even more of methoxyflurane may be recommended also for prehospital use by skilled paramedics.

Early Opiate Analgesic Requirements Following Nonsurgically Managed Tibial Fractures in Children

BACKGROUND

Many children with tibial fractures are currently being managed as outpatients. It is unclear how much opiates should be prescribed to ensure adequate analgesia at home without overprescription. This study aimed to evaluate the risk factors for requiring opiates following admission for tibial fractures and to estimate opiate requirements for children being discharged directly from the emergency department (ED).

METHODS

All children aged 4 to 16 years admitted with closed tibial fractures being treated in a molded circumferential above-knee plaster cast between October 2015 and April 2020 were included. Case notes were reviewed to identify demographics, analgesic prescriptions, and complications. Risk factors were analyzed using logistic regression.

RESULTS

A total of 75 children were included, of which 64% were males. The mean age was 9.5 (SD 3.4) years. Opiates were required by 36 (48%) children in the first 24 hours following admission. The median number of opiate doses in the first 48 hours was 0 (range: 0 to 5), with 93% of children receiving ≤3 doses. The odds of requiring opiates in the first 24 hours were unchanged for age above 10 years [odds ratio (OR)=0.85, 95% confidence interval (CI): 0.33-2.23], male sex (OR=1.58, 95% CI: 0.59-4.19), high-energy injury (OR=1.65, 95% CI: 0.45-6.04), presence of a fibula fracture (OR=2.21, 95% CI: 0.72-6.76), or need for fracture reduction in the ED (OR=0.57, 95% CI: 0.20-1.65). No children developed compartment syndrome, and the mean length of stay was 1.4 (SD 1.2) days. No children were readmitted following discharge.

CONCLUSIONS

We have found no cases of compartment syndrome or extensive requirement for opiates following closed tibial fractures treated in plaster cast. These children are candidates to be discharged directly from the ED. We have not identified any specific risk factors for the targeting of opiate analgesics. We recommend a guideline prescription of 6 doses of opiates for direct discharge from the ED to ensure adequate analgesia without overprescription.

LEVEL OF EVIDENCE

Level IV-case series.

Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality

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.

Modalités d’analgésie-sédation procédurale utilisées en traumatologie extrahospitalière par les médecins urgentistes de France métropolitaine

Introduction : L’analgésie-sédation procédurale (ASP) consiste à administrer des agents sédatifs permettant aux patients de tolérer des procédures désagréables. L’ASP a fait l’objet de recommandations formalisées d’experts de la Société française de médecine d’urgence (SFMU) depuis 2010. L’objectif était d’évaluer l’impact de ces recommandations sur les pratiques des smuristes en France concernant la réalisation d’une ASP.

Méthodes : Enquête téléphonique réalisée de janvier à juillet 2016. Nous avons joint un médecin de permanence le jour de l’appel dans chaque service mobile d’urgence et de réanimation (Smur) métropolitain. Il devait répondre à un questionnaire focalisé sur une situation clinique pour laquelle une ASP était indiquée : fracture fémorale déplacée.

Résultats : Chaque Smur métropolitain a été joint (n = 384), et 309 médecins ont répondu au questionnaire (80 %). Quarante-deux combinaisons thérapeutiques différentes ont été proposées, et 308 médecins (99 %) administraient soit un sédatif, soit un opioïde, soit les deux. La morphine était le principal antalgique utilisé (n = 232 ; 75 %), les posologies et les modalités correspondant aux dernières recommandations. La kétamine était le sédatif le plus utilisé (n = 163 ; 53 %), mais les posologies étaient inférieures à celles recommandées La douleur des patients communicants était évaluée avec une échelle adaptée. La douleur des patients non communicants, adultes ou enfants, n’était pas évaluée avec une échelle adaptée. Un tiers des Smur avait un protocole d’ASP, et 27 % des médecins disaient connaître les recommandations. Au total, il y avait une grande hétérogénéité des modalités de réalisation de l’ASP, avec notamment des difficultés de maniement des sédatifs, des recommandations peu connues et un faible taux de protocoles dans les Smur.