1
|
McArthur R, Cash RE, Rafique Z, Dickson R, Crocker K, Crowe RP, Wells M, Chu K, Nguyen J, Patrick C. Intravenous Acetaminophen Versus Ketorolac for Prehospital Analgesia: A Retrospective Data Review. J Emerg Med 2024; 67:e259-e267. [PMID: 39030089 DOI: 10.1016/j.jemermed.2024.04.007] [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: 01/17/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Parenteral ketorolac and intravenous (IV) acetaminophen have been used for prehospital analgesia, yet limited data exist on their comparative effectiveness. STUDY OBJECTIVES To evaluate the comparative effectiveness of IV acetaminophen and parenteral ketorolac for analgesia in the prehospital setting. METHODS We conducted a retrospective cross-sectional evaluation of patients receiving IV acetaminophen or parenteral ketorolac for pain management in a large suburban EMS system between 1/1/2019 and 11/30/2021. The primary outcome was change in first to last pain score. Subgroup analysis was performed on patients with traumatic pain. We used inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) to estimate the treatment effect of acetaminophen versus ketorolac among all patients and the subgroup of those with traumatic pain. RESULTS Of 2178 patients included, 856 (39.3%) received IV acetaminophen and 1322 (60.7%) received parenteral ketorolac. The unadjusted mean change in pain score was -1.9 (SD 2.4) for acetaminophen group and -2.4 (SD 2.4) for ketorolac. In the propensity score analyses, there was no statistically significant difference in pain score change for the acetaminophen group versus ketorolac among all patients (mean difference, IPTW: 0.11, 95% confidence interval [CI] -0.16, 0.37; PSM: 0.15, 95% CI -0.13, 0.43) and among those with traumatic pain (unadjusted: 0.18, 95% CI -0.35, 0.72; IPTW: 0.23, 95% CI -0.25, 0.71; PSM: -0.03, 95% CI -0.61, 0.54). CONCLUSIONS We found no statistically significant difference in mean pain reduction of IV acetaminophen and parenteral ketorolac for management of acute pain.
Collapse
Affiliation(s)
- Robert McArthur
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas.
| | | | - Zubaid Rafique
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Robert Dickson
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas; Montgomery County Hospital District EMS, Conroe, Texas
| | - Kevin Crocker
- Montgomery County Hospital District EMS, Conroe, Texas
| | | | - Michael Wells
- Montgomery County Hospital District EMS, Conroe, Texas
| | - Katherine Chu
- Sam Houston State University College of Osteopathic Medicine, Conroe, Texas
| | - James Nguyen
- Sam Houston State University College of Osteopathic Medicine, Conroe, Texas
| | - Casey Patrick
- Montgomery County Hospital District EMS, Conroe, Texas
| |
Collapse
|
2
|
Mota M, Melo F, Castelo-Branco M, Campos R, Cunha M, Santos MR. Construction of the discomfort assessment scale for immobilized trauma victims (DASITV). Int Emerg Nurs 2024; 76:101501. [PMID: 39128252 DOI: 10.1016/j.ienj.2024.101501] [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: 04/24/2024] [Revised: 06/20/2024] [Accepted: 07/20/2024] [Indexed: 08/13/2024]
Abstract
BACKGROUND Immobilization is an intervention widely administered to trauma victims and aims to reduce the victim's movements, ensuring the alignment of anatomical structures suspected of being injured. Despite the benefits of immobilization, it is responsible for the occurrence of pressure injuries, increases in intercranial pressure, pain, and discomfort. AIM To develop an instrument to assess the discomfort caused by immobilization in trauma victims - Discomfort Assessment Scale for Immobilized Trauma Victims (DASITV). METHODS A sequential mixed-methods design was used, divided into three distinct but complementary phases: (1) Conceptualization Phase - Construction of the DASITV; (2) Focus Group with a Panel of ten Technical Experts in the care of immobilized trauma victims to approve the DASITV proposal; (3) Acceptance of the scale proposal using a modified e-Delphi technique with 30 pre-hospital health professionals. RESULTS The first phase led to the construction of a scale made up of two sub-scales. The Numerical Discomfort Scale assesses the level of discomfort the person reports from 0 to 10, with 0 being no discomfort and 10 being maximum discomfort. The second evaluation parameter gives the level of pressure in mmHg that the body exerts on the surface where it is immobilized. The combined interpretation of these two sub-scales leads to 4 different possibilities - ordered by level of severity. The Focus Group made it possible to improve the scale, with input from the group of experts and, using the modified e-Delphi technique, a wider group of professionals showed agreement with the DASITV. CONCLUSION This study allowed us to propose a preliminary scale to assess the discomfort felt by victims of trauma caused by immobilization.
Collapse
Affiliation(s)
- Mauro Mota
- Department of Community Medicine, Information and Health Decision Sciences, University of Porto, Porto, Portugal; UICISA: E/ESEnfC - Cluster at the Health School of Polytechnic Institute of Viseu, Viseu, Portugal; Health School of the Polytechnic Institute of Viseu, Portugal; CINTESIS@RISE - Center for Health Technology and Services Research, University of Porto, Porto, Portugal; Academic Clinical Centre of Beiras, Portugal.
| | - Filipe Melo
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal; Active Ageing Competence Centre, Portugal
| | - Miguel Castelo-Branco
- Academic Clinical Centre of Beiras, Portugal; Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal; UBI-Health Sciencies Reserarch Centre, Portugal; University Hospital Centre of Cova da Beira, Portugal
| | - Rui Campos
- National Institute of Medical Emergêncy, Portugal
| | - Madalena Cunha
- UICISA: E/ESEnfC - Cluster at the Health School of Polytechnic Institute of Viseu, Viseu, Portugal; Health School of the Polytechnic Institute of Viseu, Portugal; Academic Clinical Centre of Beiras, Portugal
| | - Margarida Reis Santos
- CINTESIS@RISE - Center for Health Technology and Services Research, University of Porto, Porto, Portugal; Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal; Nursing School of Porto, Porto, Portugal
| |
Collapse
|
3
|
Hughey S, Cole J, Stedjelarsen E. In Response to Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments by Fink et al. Wilderness Environ Med 2024:10806032241262979. [PMID: 39043131 DOI: 10.1177/10806032241262979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Affiliation(s)
- Scott Hughey
- Department of Anesthesiology and Pain Medicine, Naval Hospital Okinawa, Okinawa, AP, Japan
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Jacob Cole
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA
- Department of Anesthesiology, Naval Medicine Center Portsmouth, Portsmouth, VA
| | - Eric Stedjelarsen
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA
- Department of Anesthesiology, Naval Medicine Center Portsmouth, Portsmouth, VA
| |
Collapse
|
4
|
McMullan JT, Droege CA, Chard KM, Otten EJ, Hart KW, Lindsell CJ, Strilka RJ. Out-of-Hospital Intranasal Ketamine as an Adjunct to Fentanyl for the Treatment of Acute Traumatic Pain: A Randomized Clinical Trial. Ann Emerg Med 2024:S0196-0644(24)00229-4. [PMID: 38864781 DOI: 10.1016/j.annemergmed.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 03/22/2024] [Accepted: 04/12/2024] [Indexed: 06/13/2024]
Abstract
STUDY OBJECTIVE To evaluate if out-of-hospital administration of fentanyl and intranasal ketamine, compared to fentanyl alone, improves early pain control after injury. METHODS We conducted an out-of-hospital randomized, placebo-controlled, blinded, parallel group clinical trial from October 2017 to December 2021. Participants were male, aged 18 to 65 years, receiving fentanyl to treat acute traumatic pain prior to hospital arrival, treated by an urban fire-based emergency medical services agency, and transported to the region's only adult Level I trauma center. Participants randomly received 50 mg intranasal ketamine or placebo. The primary outcome was the proportion with a minimum 2-point reduction in self-described pain on the verbal numerical rating scale 30 minutes after study drug administration assessed by 95% confidence interval overlap. Secondary outcomes were side effects, pain ratings, and additional pain medications through the first 3 hours of care. RESULTS Among the 192 participants enrolled, 89 (46%) were White, (median age, 36 years; interquartile range, 27 to 53 years), with 103 receiving ketamine and 89 receiving placebo. There was no difference in the proportion experiencing improved pain 30 minutes after treatment (46/103 [44.7%] ketamine versus 32/89 [36.0%] placebo; difference in proportions, 8.7%; 95% confidence interval, -5.1% to 22.5%; P=.22) or at any time point through 3 hours. There was no difference in secondary outcomes or side effects. CONCLUSION In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients.
Collapse
Affiliation(s)
- Jason T McMullan
- Division of EMS, Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH.
| | - Christopher A Droege
- Department of Pharmacy Services, UC Health, University of Cincinnati Medical Center, Cincinnati, OH; Division of Pharmacy Practice and Administration, University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH
| | - Kathleen M Chard
- Cincinnati Department of Veterans Affairs Medical Center, Cincinnati, OH; Department of Psychiatry and Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Edward J Otten
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Kim Ward Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Richard J Strilka
- 711 HPW/USAFSAM, Center for Sustainment of Trauma and Readiness Skills, Wright-Patterson Air Force Base, OH; Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH
| |
Collapse
|
5
|
Deslandes M, Deicke M, Grannemann JJ, Hinkelbein J, Hoyer A, Kalmbach M, Kobiella A, Strickmann B, Plappert T, Jansen G. Effectiveness and safety of prehospital analgesia with nalbuphine and paracetamol versus morphine by paramedics - an observational study. Scand J Trauma Resusc Emerg Med 2024; 32:41. [PMID: 38730453 PMCID: PMC11084095 DOI: 10.1186/s13049-024-01215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/28/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Despite the development of various analgesic concepts, prehospital oligoanalgesia remains very common. The present work examines prehospital analgesia by paramedics using morphine vs. nalbuphine + paracetamol. METHODS Patients with out-of-hospital-analgesia performed by paramedics from the emergency medical services of the districts of Fulda (morphine) and Gütersloh (nalbuphine + paracetamol) were evaluated with regards to pain intensity at the beginning and the end of prehospital treatment using the Numeric-Rating-Scale for pain (NRS), sex, age, and complications. The primary endpoint was achievement of adequate analgesia, defined as NRS < 4 at hospital handover, depending on the analgesics administered (nalbuphine + paracetamol vs. morphine). Pain intensity before and after receiving analgesia using the NRS, sex, age and complications were also monitored. RESULTS A total of 1,808 patients who received out-of-hospital-analgesia were evaluated (nalbuphine + paracetamol: 1,635 (90.4%), NRS-initial: 8.0 ± 1.4, NRS-at-handover: 3.7 ± 2.0; morphine: 173(9.6%), NRS-initial: 8.5 ± 1.1, NRS-at-handover: 5.1 ± 2.0). Factors influencing the difference in NRS were: initial pain intensity on the NRS (regression coefficient (RK): 0.7276, 95%CI: 0.6602-0.7950, p < 0.001), therapy with morphine vs. nalbuphine + paracetamol (RK: -1.2594, 95%CI: -1.5770 - -0.9418, p < 0.001) and traumatic vs. non-traumatic causes of pain (RK: -0.2952, 95%CI: -0.4879 - -0.1024, p = 0.002). Therapy with morphine (n = 34 (19.6%)) compared to nalbuphine + paracetamol (n = 796 (48.7%)) (odds ratio (OR): 0.274, 95%CI: 0.185-0.405, p < 0.001) and the initial NRS score (OR:0.827, 95%CI: 0.771-0.887, p < 0.001) reduced the odds of having an NRS < 4 at hospital handover. Complications occurred with morphine in n = 10 (5.8%) and with nalbuphine + paracetamol in n = 35 (2.1%) cases. Risk factors for complications were analgesia with morphine (OR: 2.690, 95%CI: 1.287-5.621, p = 0.008), female sex (OR: 2.024, 95%CI: 1.040-3.937, p = 0.0379), as well as age (OR: 1.018, 95%CI: 1.003-1.034, p = 0.02). CONCLUSIONS Compared to morphine, prehospital analgesia with nalbuphine + paracetamol yields favourable effects in terms of analgesic effectiveness and a lower rate of complications and should therefore be considered in future recommendations for prehospital analgesia.
Collapse
Affiliation(s)
- Marvin Deslandes
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Martin Deicke
- Emergency Medical Service, County of Osnabrueck, Am Schölerberg 1, 49082, Osnabrueck, Germany
- Department of Anesthesiology and operative Intensive Care Medicine, Hospital of Osnabrueck, Am Finkenhügel 1, 49076, Osnabrueck, Germany
| | - Julia Johanna Grannemann
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Jochen Hinkelbein
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany
| | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany
| | - Matthias Kalmbach
- Emergency Medical Services, City and District of Fulda, Otfrid-von-Weißenburg-Str. 3, 36043, Fulda, Germany
- Emergency Department, Klinikum Fulda, Pacelliallee 4, 36043, Fulda, Germany
| | - André Kobiella
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Bernd Strickmann
- Emergency Medical Services, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Thomas Plappert
- Emergency Medical Services, City and District of Fulda, Otfrid-von-Weißenburg-Str. 3, 36043, Fulda, Germany
- Emergency Medical Services of the Order of Malta, Region Hesse, Schmidtstrasse 67, 60326, Frankfurt/Main, Germany
| | - Gerrit Jansen
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany.
- Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany.
| |
Collapse
|
6
|
Mota M, Pires R, Cunha M, Santos MR. Nurses' perception of the impact of professional development sessions on their pre-hospital clinical practice with trauma victims. Front Public Health 2024; 12:1365509. [PMID: 38711765 PMCID: PMC11071442 DOI: 10.3389/fpubh.2024.1365509] [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: 01/04/2024] [Accepted: 04/10/2024] [Indexed: 05/08/2024] Open
Abstract
Background Continuing education is important for the quality of clinical practice because it complements it and focuses primarily on producing qualified pre-hospital nurses with operationally defined competence in nursing standards. The objective of this study was to assess pre-hospital nurses' opinion of the impact of professional development sessions on their clinical practice. Method A descriptive and quantitative study was carried out involving Portuguese pre-hospital nurses. Six professional development sessions were presented in 2020 to pre-hospital registered nurses in four of Portugal's main cities. To collect the data, at the end of each session, we apply a questionnaire designed specifically for this study. This data collection instrument consists of 11 questions, six designed to evaluate the session and five designed to evaluate the trainer responsible for the session. A five-point Likert scale was used for each question, where 1 corresponds to very dissatisfied and 5 to extremely satisfied. Results Two hundred and two nurses, which represents 55% of all Portuguese pre-hospital nurses, took part in the assessment of the professional development sessions. The nurses were from the Northern region of Portugal (51%; n = 102), the Centre region (29%; n = 59) and the Southern region of Portugal (20%; n = 41). Nurses found the session extremely satisfactory. All the assessment scores ranged between 4.4 and 4.7 points, on a scale of 1 to 5. 76.2% of the participants considered that the knowledge acquired could have a major impact [score = 5] on their future clinical practice. The majority of pre-hospital nurses (96.5%) felt that the session could have a major impact [score = 5; 76.2%, n = 154] or a very important impact [score = 4; 20.3%, n = 41] on their clinical practice. Conclusion The professional development sessions provide pre-hospital nurses with the latest research findings and the majority of nurses considered that the training had a huge impact on their clinical practice. However, it is important that future research aims to explore the cause-effect relationship between training and improved clinical practice.
Collapse
Affiliation(s)
- Mauro Mota
- Health School of the Polytechnic University of Viseu, Viseu, Portugal
- UICISA: E/ESEnfC—Cluster at the Health School of Polytechnic University of Viseu, Viseu, Portugal
- CINTESIS—Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Regina Pires
- CINTESIS—Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Nursing School of Porto, Porto, Portugal
| | - Madalena Cunha
- Health School of the Polytechnic University of Viseu, Viseu, Portugal
- UICISA: E/ESEnfC—Cluster at the Health School of Polytechnic University of Viseu, Viseu, Portugal
| | - Margarida Reis Santos
- CINTESIS—Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Nursing School of Porto, Porto, Portugal
| |
Collapse
|
7
|
Azoury SC, Matros E. Top 25 Medications the Plastic and Reconstructive Surgery Trainee Should Know for an Emergency Medicine Department Consult. Plast Reconstr Surg 2024; 153:474e-489e. [PMID: 37141488 DOI: 10.1097/prs.0000000000010609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
SUMMARY Plastic surgery trainees are often called to render care in the emergency department (eg, for established patients, trauma, burns). Broad-based knowledge in pharmacotherapeutics during these encounters is critical. This includes an understanding of pain medications, anxiolytics, local anesthetics, antibiotics, anticoagulants, antidotes, and more to ensure optimal patient care. The purpose of this report is to describe 25 frequently used and other important medications that plastic surgery trainees should know for an adult emergency department encounter.
Collapse
Affiliation(s)
- Saïd C Azoury
- From the Division of Plastic Surgery, Department of Surgery, University of Pennsylvania
| | - Evan Matros
- Division of Plastic Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center
| |
Collapse
|
8
|
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
|
9
|
Daoust R, Paquet J, Marquis M, Williamson D, Fontaine G, Chauny JM, Frégeau A, Orkin AM, Upadhye S, Lessard J, Cournoyer A. Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis. Acad Emerg Med 2023; 30:1253-1263. [PMID: 37607265 DOI: 10.1111/acem.14790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. METHODS MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. RESULTS From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). CONCLUSIONS For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.
Collapse
Affiliation(s)
- Raoul Daoust
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - Martin Marquis
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
| | - David Williamson
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, Québec, Canada
| | - Guillaume Fontaine
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean-Marc Chauny
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Amélie Frégeau
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
| | - Aaron M Orkin
- Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, St. Joseph's Health Centre, Unity Health, Toronto, Ontario, Canada
| | - Suneel Upadhye
- McMaster University, Division of Emergency Medicine, Hamilton, Ontario, Canada
| | - Justine Lessard
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| | - Alexis Cournoyer
- Study Center in Emergency Medicine, Hôpital du Sacré-Coeur de Montréal (CIUSSS du Nord-de-l'Île de-Montréal), Montréal, Québec, Canada
- Département de Médecine Familiale et de Médecine d'Urgence, Faculté de Médecine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherce, Hôpital du Sacré-Cœur de Montréal (CIUSSS du Nord de-l'Île-de-Montréal), Montréal, Québec, Canada
| |
Collapse
|
10
|
Strickmann B, Deicke M, Hoyer A, Kobiella A, Jansen G. Effectiveness and safety of prehospital analgesia including nalbuphine and paracetamol by paramedics: an observational study. Minerva Anestesiol 2023; 89:1105-1114. [PMID: 38019174 DOI: 10.23736/s0375-9393.23.17537-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND The aim of this study was to examine the effectiveness and safety of prehospital analgesia with nalbuphine and/or paracetamol by paramedics. METHODS In this retrospective trial, following the implementation of a standard-operating-procedure for pain requiring treatment as defined as a score ≥4 on the 0-10 Numeric Rating Scale for pain, all emergency operations in the district of Gütersloh between January 1, 2020, and June 30, 2022, with analgesic administration by paramedics in patients ≥18 years were included in the study. Analgesic agents employed by the paramedics included nalbuphine and/or paracetamol, butylscopolamine for abdominal colic, and esketamine in case of failure of the other analgesics. The primary endpoint was the patients' rating of their pain on the Numeric Rating Scale at the end of the operation. Additional covariates included sex, cause of pain, analgesics used, Numeric Rating Scale at beginning and analgesic-associated complications (reduced level of consciousness, hypotension, desaturation, a- or bradypnea). RESULTS A total of 1931 emergency operations (female: N.=1039 [53.8%]) with pain requiring treatment (non-traumatic cause: N.=1106 [57.3%]; initial Numeric Rating Scale: 8.0±1.4). Analgesics applied were nalbuphine + paracetamol (50.6%), paracetamol (38.7%), butylscopolamine (13.4%), nalbuphine (7.7%), and esketamine (4.9%). Mean pain reduction was 4.3±2.3 (nalbuphine + paracetamol: 5.0±2.1; nalbuphine: 4.7±2.3) and paracetamol: 3.3±2.2, respectively. Factors influencing a change in the Numeric Rating Scale were trauma (regression-coefficient: -0.308, 95% CI: -0.496 - -0.119, P=0.0014 vs. non-trauma; nalbuphine [yes vs. no]: regression-coefficient 0.684, 95% CI 0.0774-1.291, P=0.03; nalbuphine + paracetamol: regression-coefficient 0.763, 95% CI 0.227-1.299, P=0.005). At the end of the operation, 49.7% had a Numeric Rating Scale <4, 34.3% had a Numeric Rating Scale 4-5, and 16.0% had a Numeric Rating Scale ≥6. Factors influencing a Numeric Rating Scale <4 at end of use were trauma vs. non-trauma: odds ratio 0.788, 95% CI 0.649-0.957, P=0.02. The Numeric Rating Scale at beginning reported: odds ratios 0.754, 95% CI 0.700-0.812, P<0.0001. Analgesic-associated complications were not observed. CONCLUSIONS Prehospital analgesia by paramedics with nalbuphine as monotherapy or in combination with paracetamol allows for sufficient analgesia without the occurrence of complications.
Collapse
Affiliation(s)
| | | | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Bielefeld, Germany
| | | | - Gerrit Jansen
- Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Minden, Germany -
- Medical School OWL and University Medical Center OWL, Bielefeld University, Bielefeld, Germany
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Bielefeld, Germany
| |
Collapse
|
11
|
Braybrook PJ, Tohira H, Brink D, Finn J, Buzzacott PL. Analgesic agents administered by ambulance personnel to mountain bikers and hikers on trails in Western Australia. Heliyon 2023; 9:e21717. [PMID: 38027834 PMCID: PMC10651519 DOI: 10.1016/j.heliyon.2023.e21717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Paul J. Braybrook
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
- St John Western Australia, Belmont, Western Australia, Australia
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
- Discipline of Emergency Medicine, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Deon Brink
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
- St John Western Australia, Belmont, Western Australia, Australia
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
- St John Western Australia, Belmont, Western Australia, Australia
- Discipline of Emergency Medicine, Medical School, The University of Western Australia, Perth, Western Australia, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter L. Buzzacott
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
12
|
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
|
13
|
Basco WT, Bundy DG, Garner SS, Ebeling M, Simpson KN. Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000-2020. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095681. [PMID: 37174201 PMCID: PMC10178489 DOI: 10.3390/ijerph20095681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/15/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023]
Abstract
Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0-18 years old between 2000-2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran-Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926-0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000-2020, adolescents 12-18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.
Collapse
Affiliation(s)
- William T Basco
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - David G Bundy
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Sandra S Garner
- Department of Clinical Pharmacy and Outcome Sciences, College of Pharmacy, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Myla Ebeling
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kit N Simpson
- Department of Healthcare Leadership & Management, College of Health Professions, The Medical University of South Carolina, Charleston, SC 29425, USA
| |
Collapse
|
14
|
Powell JR, Browne LR, Guild K, Shah MI, Crowe RP, Lindbeck G, Braithwaite S, Lang ES, Panchal AR. Evidence-Based Guidelines for Prehospital Pain Management: Literature and Methods. PREHOSP EMERG CARE 2023; 27:154-161. [PMID: 34928783 DOI: 10.1080/10903127.2021.2018074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Emergency Medical Services (EMS) clinicians commonly encounter patients with acute pain. A new set of evidence-based guidelines (EBG) was developed to assist in the prehospital management of pain. Our objective was to describe the methods used to develop these evidence-based guidelines for prehospital pain management. METHODS The EBG development process was supported by a previous systematic review conducted by the Agency for Healthcare Research and Quality (AHRQ) covering nine different population, intervention, comparison, and outcome (PICO) questions. A technical expert panel (TEP) was formed and added an additional pediatric-specific PICO question. Identified evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and tabulated into Summary of Findings tables. The TEP then utilized a rigorous systematic method, including the PanelVoice function, for recommendation development which was applied to generate Evidence to Decision Tables (EtD). This process involved review of the Summary of Findings tables, asynchronous member judging, and facilitated panel discussion to generate final consensus-based recommendations. RESULTS The work product described above was completed by the TEP panel from September 2020 to April 2021. For these recommendations, the overall certainty of evidence was very low or low, data for decisions on cost effectiveness and equity were lacking, and feasibility was rated well across all categories. Based on the evidence, one strong and seven conditional recommendations were made, with two PICO questions lacking sufficient evidence to generate a recommendation. CONCLUSION We describe a protocol that leveraged established EBG development techniques, the GRADE framework in conjunction with a previous AHRQ systematic review to develop treatment recommendations for prehospital pain management. This process allowed for mitigation of many confounders due to the use of virtual and electronic communication. Our approach may inform future guideline development and increase transparency in the prehospital recommendations development processes.
Collapse
Affiliation(s)
- Jonathan R Powell
- National Registry of Emergency Medical Technicians, Columbus, Ohio.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio
| | - Lorin R Browne
- Medical College of Wisconsin, Milwaukee County EMS, Milwaukee, Wisconsin
| | - Kyle Guild
- Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Manish I Shah
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - George Lindbeck
- Office of Emergency Medical Services, Virginia Department of Health, and the Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Sabina Braithwaite
- Missouri Department of Health and Senior Services, and the Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Eddy S Lang
- Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians, Columbus, Ohio.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio.,Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | |
Collapse
|
15
|
Watso JC, Huang M, Hendrix JM, Belval LN, Moralez G, Cramer MN, Foster J, Hinojosa-Laborde C, Crandall CG. Comparing the Effects of Low-Dose Ketamine, Fentanyl, and Morphine on Hemorrhagic Tolerance and Analgesia in Humans. PREHOSP EMERG CARE 2023; 27:600-612. [PMID: 36689353 PMCID: PMC10329983 DOI: 10.1080/10903127.2023.2172493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/09/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023]
Abstract
Hemorrhage is a leading cause of preventable battlefield and civilian trauma deaths. Ketamine, fentanyl, and morphine are recommended analgesics for use in the prehospital (i.e., field) setting to reduce pain. However, it is unknown whether any of these analgesics reduce hemorrhagic tolerance in humans. We tested the hypothesis that fentanyl (75 µg) and morphine (5 mg), but not ketamine (20 mg), would reduce tolerance to simulated hemorrhage in conscious humans. Each of the three analgesics was evaluated independently among different cohorts of healthy adults in a randomized, crossover (within drug/placebo comparison), placebo-controlled fashion using doses derived from the Tactical Combat Casualty Care Guidelines for Medical Personnel. One minute after an intravenous infusion of the analgesic or placebo (saline), we employed a pre-syncopal limited progressive lower-body negative pressure (LBNP) protocol to determine hemorrhagic tolerance. Hemorrhagic tolerance was quantified as a cumulative stress index (CSI), which is the sum of products of the LBNP and the duration (e.g., [40 mmHg x 3 min] + [50 mmHg x 3 min] …). Compared with ketamine (p = 0.002 post hoc result) and fentanyl (p = 0.02 post hoc result), morphine reduced the CSI (ketamine (n = 30): 99 [73-139], fentanyl (n = 28): 95 [68-130], morphine (n = 30): 62 [35-85]; values expressed as a % of the respective placebo trial's CSI; median [IQR]; Kruskal-Wallis test p = 0.002). Morphine-induced reductions in tolerance to central hypovolemia were not well explained by a prediction model including biological sex, body mass, and age (R2=0.05, p = 0.74). These experimental data demonstrate that morphine reduces tolerance to simulated hemorrhage while fentanyl and ketamine do not affect tolerance. Thus, these laboratory-based data, captured via simulated hemorrhage, suggest that morphine should not be used for a hemorrhaging individual in the prehospital setting.
Collapse
Affiliation(s)
- Joseph Charles Watso
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, Florida, USA
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mu Huang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Office of Science, Medicine, and Health, American Heart Association, Dallas, Texas, USA
| | - Joseph Maxwell Hendrix
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Luke Norman Belval
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gilbert Moralez
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew Nathaniel Cramer
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josh Foster
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Craig Gerald Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
16
|
Mahmood A, Hunt N, Masiewicz S, Cranford JA, Noel S, Brent C, Wagner D. Treating Prehospital Pain in Children: A Retrospective Chart Review Comparing the Safety and Efficacy of Prehospital Pediatric Ketamine and Opioid Analgesia. J Pain Palliat Care Pharmacother 2023:1-10. [PMID: 36716228 DOI: 10.1080/15360288.2023.2169433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Prior to 2020, pain management in the Washtenaw/Livingston County Medical Control Authority (W/L MCA) Emergency Medical Service (EMS) system in Southeast Michigan was limited to morphine, fentanyl, ketorolac, and acetaminophen. Based on the increasing evidence describing its safety and efficacy, ketamine was added to local protocols for pain management. This study aimed to evaluate differences in pain management and adverse effects of ketamine and opioid administration. Data from pediatric patients who received ketamine or an opioid in the W/L MCA EMS system from October 2019 to March 2021 were analyzed. The primary outcome was the difference in pain score, and the secondary outcome was adverse effects observed after analgesic administration. The decrease in pain scores was greater among ketamine patients (mean: 5.2) compared to opioid patients (mean: 2.9), p < 0.001. The prevalence of adverse effects was higher among patients in the ketamine group (28.6%) compared to patients in the opioid group (2.4%, p < 0.001). Of 14 patients who received ketamine, one 17-year-old male experienced mild anxiety (7.1%), two teenage females experienced mild dissociation (14.3%), and one 20-year-old female experienced mild nausea (7.1%). Overall, ketamine is a safe and effective option compared to opioids for pediatric patients experiencing moderate to severe prehospital pain.
Collapse
Affiliation(s)
- Amima Mahmood
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Nathaniel Hunt
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Spencer Masiewicz
- Department of Emergency Medicine, Northeast Georgia Health System, Gainesville, GA, USA
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Stacey Noel
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Christine Brent
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Deborah Wagner
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA.,C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| |
Collapse
|
17
|
Forghani M, Nasr Esfahani M, Vali M. Comparison of the Effect of Intravenous Fentanyl with Low-Dose Ketamine on Pain Relief in Patients Taking Methadone and Suffering from Limb Fractures. Adv Biomed Res 2023; 12:7. [PMID: 36926435 PMCID: PMC10012033 DOI: 10.4103/abr.abr_166_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/15/2021] [Accepted: 01/02/2022] [Indexed: 02/05/2023] Open
Abstract
Background Given the significance of pain control in addicted patients and the prominence of not using opioids due to patient's drug dependence, the present study aimed at comparing and evaluating the effect of intravenous fentanyl with low-dose ketamine on pain relief in patients taking methadone and suffering from limb fractures. Materials and Methods The present double-blind randomized clinical trial was performed on 100 patients taking methadone and suffering from limb fractures. The patients were divided into two groups receiving 1 μg/kg single dose of fentanyl and 0.3 mg/kg single dose of ketamine (low-dose ketamine). Patients' pain scores and the incidence rate of complications were recorded before the intervention, and 15, 30, and 60 min after drug administration and were then compared between the two groups. Results The mean pain score of patients 15 min after the intervention was significantly lower in the low-dose ketamine group with a mean of 2.50 ± 1.34 as compared with the fentanyl group with a mean of 7.10 ± 1.43 (P < 0.001). However, the mean pain score was not significantly different between the two groups 30 and 60 min after the intervention (P > 0.05). In addition, the incidence rate of complications was not significantly different between the two groups (P > 0.05). Conclusion According to the results of this study, low-dose ketamine as compared with fentanyl relieves pain in the mentioned patients with a faster effect and in a shorter time although no difference can be found between the pain scores of the two groups 30 and 60 min after the intervention.
Collapse
Affiliation(s)
- Mohsen Forghani
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Marzie Vali
- Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
18
|
Kolli S, Friedman BW, Latev A, Chang AK, Naeem F, Feliciano C, Afrifa F, Walker C, Izzo A, Irizarry E. A Randomized Study of Intravenous Hydromorphone Versus Intravenous Acetaminophen for Older Adult Patients with Acute Severe Pain. Ann Emerg Med 2022; 80:432-439. [PMID: 35965162 PMCID: PMC9588558 DOI: 10.1016/j.annemergmed.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/05/2022] [Accepted: 06/16/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE We conducted a randomized study to compare the efficacy and adverse event profile of 1,000 mg of intravenous acetaminophen to that of 0.5 mg of intravenous hydromorphone among patients aged 65 years or more with acute pain of severity that was sufficient enough to warrant intravenous opioids. METHODS This randomized comparative effectiveness study with 162 participants was conducted in 2 urban emergency departments (EDs). The primary outcome was an improvement in a 0 to 10 pain scale from baseline to 60 minutes later. Secondary outcomes included the need for additional analgesic medication and adverse events that were attributable to the investigational medication. The minimum clinically important difference was an improvement of 1.3 on the 0 to 10 pain scale. RESULTS The median baseline pain score was 10 (interquartile range 8 to 10) in both the groups. By 60 minutes, patients taking acetaminophen improved by 3.6 (standard deviation 2.9) on the 0 to 10 pain scale, whereas patients taking hydromorphone improved by 4.6 (standard deviation 3.3) (95% confidence interval [CI] for the difference of 1.0 was 0.1 to 2.0). Additional analgesic medications were required for 37 (46%) of 81 patients taking acetaminophen and 31 (38%) of 81 patients taking hydromorphone (95% CI for the rounded difference of 7% was -8% to 23%). Adverse events were reported by 6 (7%) of 81 patients taking acetaminophen and 10 (12%) of 81 patients taking hydromorphone (95% CI for the difference of 5% was -4% to 14%) and included dizziness, drowsiness, headache, and nausea. CONCLUSION Although 0.5 mg of the intravenously administered hydromorphone was statistically superior to 1,000 mg of intravenous acetaminophen administered in older patients with acute severe pain in the ED, this difference was not clinically significant. Regardless of the medication received, many participants experienced minimal or incomplete pain relief.
Collapse
Affiliation(s)
- Shilpa Kolli
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Alex Latev
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Andrew K Chang
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Farnia Naeem
- Department of Emergency Medicine, Mount Sinai Health System, New York, NY
| | - Carmen Feliciano
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | | | - Christopher Walker
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Al Izzo
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| | - Eddie Irizarry
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore, Bronx, NY
| |
Collapse
|
19
|
Ferri P, Gambaretto C, Alberti S, Parogni P, Rovesti S, Di Lorenzo R, Sollami A, Bargellini A. Pain Management in a Prehospital Emergency Setting: A Retrospective Observational Study. J Pain Res 2022; 15:3433-3445. [PMID: 36324866 PMCID: PMC9621014 DOI: 10.2147/jpr.s376586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/23/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose Acute pain is a prevalent symptomatology in prehospital emergency care. Although inadequate assessment and treatment of acute pain are associated with various complications, about 43% of adults suffering from pain are undertreated. This phenomenon is poorly studied, and limited data are available in the literature. The objective was to investigate the pain management in a prehospital emergency health-care setting, verifying pain assessment, pharmacological treatment adherence and the effectiveness of pain relief therapy. Patients and Methods A retrospective observational study was conducted in a sample including all adults treated by the professionals of nurse-staffed ambulances and medical cars in an Italian Emergency Medical Services (EMS) from 1 January 2019 to 31 May 2019. We collected both demographic information and Numeric Rating Scale scores, which evaluated presence and intensity of pain, from the EMS paper forms. All analyses were performed using SPSS, version 27. Results The study sample was composed of 629 people: 310 males (49%) and 319 females (51%), with an average age of 64.2±22 years (range 18-108). Pain information was collected in 75.5% (n = 475) of our sample; among them 222 patients (46.7%) suffered from pain. We recorded that 79.7% (n = 177) of the subjects with pain received no pharmacological treatment, and in almost all of the treated cases they did not adhere to the analgesia algorithm in use. Among those who were pharmacologically treated, pain statistically significantly decreased in intensity, from before to after, in both emergency vehicles (nurse-staffed ambulances pre m = 8.36±0.9 vs post m = 4.18±2.2, p<0.001; medical cars pre m = 7.25±1.7 vs post m = 3.50±2.6, p<0.001). Subsequently, pain was only re-ascertained in 24.3% of subjects. Conclusion Our findings confirm that pain is a prevalent symptom in prehospital patients, especially in the younger age range, but that it remains an underrecognized, underestimated, and undertreated symptom with the risk of causing worse health outcomes.
Collapse
Affiliation(s)
- Paola Ferri
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Sara Alberti
- Clinical and Experimental Medicine PhD Program, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy,Correspondence: Sara Alberti, Clinical and Experimental Medicine PhD Program, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, 41125, Italy, Tel +390592055599, Email
| | | | - Sergio Rovesti
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Rosaria Di Lorenzo
- Department of Mental Health and Drug Abuse, AUSL of Modena, Modena, Italy
| | - Alfonso Sollami
- Health Professions Service, University Hospital of Parma, Parma, Italy
| | - Annalisa Bargellini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
20
|
Rangel T, Pham S, Senger B, Daratha K, Fitzgerald C, Mallo R, Daratha K. Pharmacologic Pain Management Trends among Adults Hospitalized with Cellulitis: An Evidence-Based Practice Project. Pain Manag Nurs 2022; 24:222-228. [PMID: 36220690 DOI: 10.1016/j.pmn.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 08/15/2022] [Accepted: 09/07/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Nurses commonly administer opioids, following "as needed" order sets, to patients hospitalized for acute pain conditions like cellulitis. Practice guidelines recommend limiting opioid administration for acute pain management. At two hospitals in the Pacific Northwest, an opioid stewardship committee was formed to align with best practice. AIMS The main objective was to describe changes to inpatient rates of opioid and non-opioid administration following implementation of evidence-based opioid stewardship efforts. DESIGN Observational, retrospective, evidence-based practice project. SETTINGS One 200-bed and one 680-bed hospital in Washington State. PARTICIPANTS/SUBJECTS Data were included from patients aged 18 years or older hospitalized for cellulitis. METHODS Demographic and pain-related data were extracted from the electronic health record (n = 4,523 encounters) guided by the symptom management framework. The proportion of patients receiving opioid or non-opioid medications before and after implementation of evidence-based practice opioid stewardship interventions was calculated descriptively. A logistic regression tested factors related to administration of an opioid medication. RESULTS The proportion of patients receiving an opioid decreased following opioid stewardship efforts while those receiving non-opioid analgesics remained stable. Factors significantly influencing inpatient opioid administration were: average inpatient pain score, pre-hospital opioid prescription, length of stay, and year of hospitalization. CONCLUSIONS Analgesic administration treating painful, acute cellulitis at two hospitals in the Pacific Northwest included opioid and non-opioid medications. The proportion of patients receiving opioids decreased following best practice opioid stewardship actions. Opportunities may exist for nurses to collaborate with providers to improve inpatient analgesic administration practices.
Collapse
Affiliation(s)
- Teresa Rangel
- Providence Health Care, Professional Development Department, Spokane, Washington.
| | - Sydney Pham
- Providence Sacred Heart Medical Center, Spokane, Washington
| | - Brenda Senger
- Gonzaga University, School of Human Physiology and Nursing, Spokane, Washington
| | - Kristopher Daratha
- Providence Health Care, Professional Development Department, Spokane, Washington
| | - Cynthia Fitzgerald
- Providence Health Care, Professional Development Department, Spokane, Washington
| | - Rebecca Mallo
- Providence Sacred Heart Medical Center, Spokane, Washington
| | - Kenneth Daratha
- Providence Health Care, Providence Medical Research Center, Spokane, Washington
| |
Collapse
|
21
|
Nutbeam T, Brandling J, Wallis LA, Stassen W. Understanding people's experiences of extrication while being trapped in motor vehicles: a qualitative interview study. BMJ Open 2022; 12:e063798. [PMID: 36127106 PMCID: PMC9490624 DOI: 10.1136/bmjopen-2022-063798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To explore patient's experience of entrapment and subsequent extrication following a motor vehicle collision and identify their priorities in optimising this experience. DESIGN Semistructured interviews exploring the experience of entrapment and extrication conducted at least 6 weeks following the event. Thematic analysis of interviews. SETTING Single air ambulance and spinal cord injury charity in the UK. PARTICIPANTS 10 patients were recruited and consented; six air ambulance patients and two spinal cord injury charity patients attended the interview. 2 air ambulance patients declined to participate following consent due to the perceived potential for psychological sequelae. RESULTS The main theme across all participants was that of the importance of communication; successful communication to the trapped patient resulted in a sense of well-being and where communication failures occurred this led to distress. The data generated three key subthemes: 'on-scene communication', 'physical needs' and 'emotional needs'. Specific practices were identified that were of use to patients during entrapment and extrication. CONCLUSIONS Extrication experience was improved by positive communication, companionship, explanations and planned postincident follow-up. Extrication experience was negatively affected by failures in communication, loss of autonomy, unmanaged pain, delayed communication with remote family and onlooker use of social media. Recommendations which will support a positive patient-centred extrication experience are the presence of an 'extrication buddy', the use of clear and accessible language, appropriate reassurance in relation to co-occupants, a supportive approach to communication with family and friends, the minimisation of onlooker photo/videography and the provision of planned (non-clinical) follow-up.
Collapse
Affiliation(s)
- Tim Nutbeam
- Department of Emergency Medicine, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
- Devon Air Ambulance, Exeter, UK
| | - Janet Brandling
- Qualitative Researcher and Psychotherapist, Unaffiliated, Bristol, UK
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Rondebosch, South Africa
| |
Collapse
|
22
|
Randall MM, Raae-Nielsen J, Choi M, Dukes WS, Nesper T, Mesisca MK. Incidence of Dissociation With Low-Dose Pre-hospital Ketamine in Geriatric Patients With Trauma-Related Pain. Cureus 2022; 14:e27698. [PMID: 36081959 PMCID: PMC9440993 DOI: 10.7759/cureus.27698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Sub-dissociative ketamine has been used increasingly for the treatment of acute pain in a wide variety of settings. While there are studies evaluating its use in the geriatric population, no studies have described its safety in the pre-hospital geriatric trauma patient. The objective of this study was to define the incidence of dissociation with low-dose pre-hospital ketamine in geriatric trauma patients. Methods Using our county emergency medical services database, we identified all trauma patients greater or equal to 65 years of age who received pre-hospital ketamine for pain after the implementation of a low-dose ketamine protocol. We retrospectively reviewed pre-hospital and emergency department records for demographics, traumatic injuries, Glasgow Coma Score, emergency department length of stay and disposition, and hospital length of stay. This group was compared to a similar population of trauma patients, transported prior to the ketamine protocol. The comparison group was chosen by matching the ketamine group to more than double the number of non-ketamine patients. Records were obtained from two separate trauma centers. Our primary outcome was documentation of “ketamine-related dissociation” by either the pre-hospital, emergency department or trauma provider. Secondary outcomes included emergency department length of stay and intensive care unit admission. Results Seventy-nine patients received ketamine with records available for analysis. One hundred ninety-three non-ketamine patients were compared to this group. There were nosignificant differences between the two groups in regards to age, weight, gender, or mechanism of injury. The injury severity score was higher in the ketamine group. Nine patients (11%) had documented dissociation after ketamine, with six of these patients back to baseline mentation by arrival to the emergency department. The emergency department length of stay was shorter in the ketamine group. The rate of intensive care unit admission was the same between both groups. Conclusions Pre-hospital sub-dissociative ketamine in geriatric trauma patients is associated with brief episodes of dissociation in a small minority of patients.
Collapse
|
23
|
Watso JC, Belval LN, Cimino FA, Orth BD, Hendrix JM, Huang M, Johnson E, Foster J, Hinojosa-Laborde C, Crandall CG. Low-dose morphine reduces pain perception and blood pressure, but not muscle sympathetic outflow, responses during the cold pressor test. Am J Physiol Heart Circ Physiol 2022; 323:H223-H234. [PMID: 35714174 PMCID: PMC9273278 DOI: 10.1152/ajpheart.00092.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 11/22/2022]
Abstract
Our knowledge about how low-dose (analgesic) morphine affects autonomic cardiovascular regulation is primarily limited to animal experiments. Notably, it is unknown if low-dose morphine affects human autonomic cardiovascular responses during painful stimuli in conscious humans. Therefore, we tested the hypothesis that low-dose morphine reduces perceived pain and subsequent sympathetic and cardiovascular responses in humans during an experimental noxious stimulus. Twenty-nine participants (14 females/15 males; 29 ± 6 yr; 26 ± 4 kg·m-2, means ± SD) completed this randomized, crossover, placebo-controlled trial during two laboratory visits. During each visit, participants completed a cold pressor test (CPT; hand in ∼0.4°C ice bath for 2 min) before and ∼35 min after drug/placebo administration (5 mg iv morphine or saline). We compared pain perception (100 mm visual analog scale), muscle sympathetic nerve activity (MSNA; microneurography; 14 paired recordings), and beat-to-beat blood pressure (BP; photoplethysmography) between trials (at both pre- and postdrug/placebo time points) using paired, two-tailed t tests. Before drug/placebo infusion, perceived pain (P = 0.92), ΔMSNA burst frequency (n = 14, P = 0.21), and Δmean BP (P = 0.39) during the CPT were not different between trials. After the drug/placebo infusion, morphine versus placebo attenuated perceived pain (morphine: 43 ± 20 vs. placebo: 57 ± 24 mm, P < 0.001) and Δmean BP (morphine: 10 ± 7 vs. placebo: 13 ± 8 mmHg, P = 0.003), but not ΔMSNA burst frequency (morphine: 10 ± 11 vs. placebo: 13 ± 11 bursts·min-1, P = 0.12), during the CPT. Reductions in pain perception and Δmean BP were only weakly related (r = 0.34, P = 0.07; postmorphine CPT minus postplacebo CPT). These data provide valuable information regarding how low-dose morphine affects autonomic cardiovascular responses during an experimental painful stimulus.NEW & NOTEWORTHY In this randomized, crossover, placebo-controlled trial, we found that low-dose morphine administration reduced pain perception and blood pressure responses during the cold pressor test via attenuated increases in heart rate and cardiac output. We also determined that muscle sympathetic outflow responses during the cold pressor test seem to be unaffected by low-dose morphine administration. Finally, our exploratory analysis suggests that biological sex does not influence morphine-induced antinociception in healthy adults.
Collapse
Affiliation(s)
- Joseph C Watso
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luke N Belval
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Frank A Cimino
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Bonnie D Orth
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Joseph M Hendrix
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mu Huang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elias Johnson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Josh Foster
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carmen Hinojosa-Laborde
- United States Army Institute of Surgical Research, Joint Base San Antonio-Fort Sam Houston, San Antonio, Texas
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
24
|
Watso JC, Belval LN, Cimino FA, Orth BD, Hendrix JM, Huang M, Johnson E, Foster J, Hinojosa-Laborde C, Crandall CG. Low-dose morphine reduces tolerance to central hypovolemia in healthy adults without affecting muscle sympathetic outflow. Am J Physiol Heart Circ Physiol 2022; 323:H89-H99. [PMID: 35452317 PMCID: PMC9190738 DOI: 10.1152/ajpheart.00091.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/22/2022]
Abstract
Hemorrhage is a leading cause of preventable battlefield and civilian trauma deaths. Low-dose (i.e., an analgesic dose) morphine is recommended for use in the prehospital (i.e., field) setting. Morphine administration reduces hemorrhagic tolerance in rodents. However, it is unknown whether morphine impairs autonomic cardiovascular regulation and consequently reduces hemorrhagic tolerance in humans. Thus, the purpose of this study was to test the hypothesis that low-dose morphine reduces hemorrhagic tolerance in conscious humans. Thirty adults (15 women/15 men; 29 ± 6 yr; 26 ± 4 kg·m-2, means ± SD) completed this randomized, crossover, double-blinded, placebo-controlled trial. One minute after intravenous administration of morphine (5 mg) or placebo (saline), we used a presyncopal limited progressive lower-body negative pressure (LBNP) protocol to determine hemorrhagic tolerance. Hemorrhagic tolerance was quantified as a cumulative stress index (mmHg·min), which was compared between trials using a Wilcoxon matched-pairs signed-rank test. We also compared muscle sympathetic nerve activity (MSNA; microneurography) and beat-to-beat blood pressure (photoplethysmography) during the LBNP test using mixed-effects analyses [time (LBNP stage) × trial]. Median LBNP tolerance was lower during morphine trials (placebo: 692 [473-997] vs. morphine: 385 [251-728] mmHg·min, P < 0.001, CI: -394 to -128). Systolic blood pressure was 8 mmHg lower during moderate central hypovolemia during morphine trials (post hoc P = 0.02; time: P < 0.001, trial: P = 0.13, interaction: P = 0.006). MSNA burst frequency responses were not different between trials (time: P < 0.001, trial: P = 0.80, interaction: P = 0.51). These data demonstrate that low-dose morphine reduces hemorrhagic tolerance in conscious humans. Thus, morphine is not an ideal analgesic for a hemorrhaging individual in the prehospital setting.NEW & NOTEWORTHY In this randomized, crossover, placebo-controlled trial, we found that tolerance to simulated hemorrhage was lower after low-dose morphine administration. Such reductions in hemorrhagic tolerance were observed without differences in MSNA burst frequency responses between morphine and placebo trials. These data, the first to be obtained in conscious humans, demonstrate that low-dose morphine reduces hemorrhagic tolerance. Thus, morphine is not an ideal analgesic for a hemorrhaging individual in the prehospital setting.
Collapse
Affiliation(s)
- Joseph C Watso
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luke N Belval
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Frank A Cimino
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Bonnie D Orth
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Joseph M Hendrix
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mu Huang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elias Johnson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Josh Foster
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carmen Hinojosa-Laborde
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Houston, Texas
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
25
|
Xing Y, Zhou L, Yu J, Wang Z, Ding Z, Xie C, Li Y, Wang F, Tang L. Analgesic efficacy of nitrous oxide in adults in the emergency department: A meta-analysis of randomized controlled trials. Am J Emerg Med 2022; 56:92-99. [DOI: 10.1016/j.ajem.2022.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 03/06/2022] [Accepted: 03/13/2022] [Indexed: 11/24/2022] Open
|
26
|
Tratamento pré-hospitalar da dor traumática aguda: um estudo observacional. ACTA PAUL ENFERM 2022. [DOI: 10.37689/acta-ape/2022ao001834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
27
|
Eltorki M, Busse JW, Freedman SB, Thompson G, Beattie K, Serbanescu C, Carciumaru R, Thabane L, Ali S. Intravenous ketorolac versus morphine in children presenting with suspected appendicitis: a pilot single-centre non-inferiority randomised controlled trial. BMJ Open 2022; 12:e056499. [PMID: 35383071 PMCID: PMC8984007 DOI: 10.1136/bmjopen-2021-056499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Despite a lack of evidence demonstrating superiority to non-steroidal anti-inflammatory drugs, like ketorolac, that are associated with lower risk of harms, opioids remain the most prescribed analgesic for acute abdominal pain. In this pilot trial, we will assess the feasibility of a definitive trial comparing ketorolac with morphine in children with suspected appendicitis. We hypothesise that our study will be feasible based on a 40% consent rate. METHODS AND ANALYSIS A single-centre, non-inferiority, blinded (participant, clinician, investigators and outcome assessors), double-dummy randomised controlled trial of children aged 6-17 years presenting to a paediatric emergency department with ≤5 days of moderate to severe abdominal pain (≥5 on a Verbal Numerical Rating Scale) and are investigated for appendicitis. We will use variable randomised blocks of 4-6 and allocate participants in 1:1 ratio to receive either intravenous (IV) ketorolac 0.5 mg/kg+IV morphine placebo or IV morphine 0.1 mg/kg+IV ketorolac placebo. Analgesic co-intervention will be limited to acetaminophen (commonly used as first-line therapy). Participants in both groups will be allowed rescue therapy (morphine 0.5 mg/kg) within 60 min of our intervention. Our primary feasibility outcome is the proportion of eligible patients approached who provide informed consent and are enrolled in our trial. Our threshold for feasibility will be to achieve a ≥40% consent rate, and we will enrol 100 participants into our pilot trial. ETHICS AND DISSEMINATION Our study has received full approval by the Hamilton integrated Research Ethics Board. We will disseminate our study findings at national and international paediatric research conferences to garner interest and engage sites for a future multicentre definitive trial. TRIAL REGISTRATION NCT04528563, Pre-results.
Collapse
Affiliation(s)
- Mohamed Eltorki
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Jason W Busse
- Department of Health Research Methods, Evidence & Impact, McMaster, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | - Graham Thompson
- Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Karen Beattie
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Redjana Carciumaru
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Pediatrics, McMaster University, Faculty of Health Sciences, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- St Joseph's Research Institute, St Joseph's Health Care, Hamilton, Ontario, Canada
| | - Samina Ali
- Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| |
Collapse
|
28
|
Friesgaard KD, Vist GE, Hyldmo PK, Raatiniemi L, Kurola J, Larsen R, Kongstad P, Magnusson V, Sandberg M, Rehn M, Rognås L. Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review. Pain Ther 2022; 11:17-36. [PMID: 35041151 PMCID: PMC8861251 DOI: 10.1007/s40122-021-00346-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/10/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies. METHODS The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method. RESULTS A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine. CONCLUSIONS Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.
Collapse
Affiliation(s)
- Kristian Dahl Friesgaard
- Research Department, Prehospital Emergency Medical Service, Central Denmark Region, Olof Palmes Allé 34, 8200, Aarhus, Denmark. .,Department of Anaesthesiology, Regional Hospital of Horsens, Horsens, Denmark. .,Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Gunn Elisabeth Vist
- Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Per Kristian Hyldmo
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.,Trauma Unit, Sørlandet Hospital, Kristiansand, Norway
| | - Lasse Raatiniemi
- Centre for Prehospital Emergency Care, Oulu University Hospital, Oulu, Finland.,Anaesthesia Research Group, MRC, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Jouni Kurola
- Centre for Prehospital Emergency Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Robert Larsen
- Department of Biomedical and Clinical Sciences (BKV), Linköping University, Linköping, Sweden
| | - Poul Kongstad
- Department of Prehospital Care and Disaster Medicine, Region of Skåne, Lund, Sweden
| | | | - Mårten Sandberg
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
| | - Marius Rehn
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway.,Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
| | - Leif Rognås
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Air Ambulance, Aarhus, Denmark
| |
Collapse
|
29
|
Bebarta GE, Bebarta VS, Fisher AD, April MD, Atkinson AJ, McGhee LL, Schauer SG. An Analysis of Ketamine Doses Administrated to Nonintubated Casualties Prehospital. Mil Med 2021; 188:usab511. [PMID: 34865120 DOI: 10.1093/milmed/usab511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/21/2021] [Accepted: 11/24/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Previous studies demonstrate that a significant proportion of casualties do not receive pain medication prehospital after traumatic injuries. To address possible reasons, the U.S. Military has sought to develop novel delivery methods to aid in administration of pain medications prehospital. We sought to describe the dose and route of ketamine administered prehospital to help inform materiel solutions. MATERIALS AND METHODS This is a secondary analysis of a previously described dataset focused on prehospital data within the Department of Defense Trauma Registry from 2007 to 2020. We isolated encounters in which ketamine was administered along with the amount dosed and the route of administration in nonintubated patients. RESULTS Within our dataset, 862 casualties met inclusion for this analysis. The median age was 28 and nearly all (98%) were male. Most were battle injuries (88%) caused by explosives (54%). The median injury severity score was 10 with the extremities accounting to the most frequent seriously injured body region (38%). The mean dose via intravenous route was 50.4 mg (n = 743, 95% CI 46.5-54.3), intramuscular was 66.7 mg (n = 234, 95% CI 60.3-73.1), intranasal was 56.5 mg (n = 10, 39.1-73.8), and intraosseous was 83.3 mg (n = 34, 66.3-100.4). Most had a medic or CLS in their chain of care (87%) with air evacuation as the primary mechanism of evacuation (86%). CONCLUSIONS The average doses administered were generally larger than the doses recommended by Tactical Combat Casualty Care guidelines. Currently, guidelines may underdose analgesia. Our data will help inform materiel solutions based on end-user requirements.
Collapse
Affiliation(s)
| | | | - Andrew D Fisher
- University of New Mexico Hospital, Albuquerque, NM, USA
- Texas National Guard, Arlington, TX, USA
| | - Michael D April
- 40th Forward Resuscitative Surgical Detachment, Fort Carson, CO 80913, USA
| | - Andrew J Atkinson
- US Army Medical Materiel Development Activity, Fort Detrick, MD, USA
| | - Laura L McGhee
- US Army Medical Materiel Development Activity, Fort Detrick, MD, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| |
Collapse
|
30
|
Basco WT, McCauley JL, Zhang J, Marsden JE, Simpson KN, Heidari K, Mauldin PD, Ball SJ. High-risk opioid analgesic dispensing to adolescents 12-18 years old in South Carolina: 2010-2017. Pharmacoepidemiol Drug Saf 2021; 31:353-360. [PMID: 34859532 DOI: 10.1002/pds.5389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/09/2022]
Abstract
PURPOSE To evaluate "high-risk" opioid dispensing to adolescents, including daily morphine milligram equivalents (MME) above recommended amounts, the percentage of extended-release opioid prescriptions dispensed to opioid-naïve adolescents, and concurrent use of opioids and benzodiazepines, and to evaluate changes in those rates over time. METHODS Retrospective cohort study of one state's prescription drug monitoring program data (2010-2017), evaluating adolescents 12-18 years old dispensed opioid analgesic prescriptions. Outcomes of interest were the quarterly frequencies of the high-risk measures. We utilized generalized linear regression to determine whether the rate of the outcomes changed over time. RESULTS The quarterly percentage of adolescents ages 12-18 years old dispensed an opioid who received ≥90 daily MME declined from 4.1% in the first quarter (Q1) of 2010 to 3.4% in the final quarter (Q4) of 2017 (p < 0.0001). The frequency of adolescents dispensed ≥50 daily MME changed little over time. In 2010, the percentage of adolescents receiving an extended-release opioid who were opioid naïve was 60.7%, declining to 50.6% by Q4 of 2017 (p > 0.10 overall change 2010-2017). The percentage of adolescent opioid days overlapping with benzodiazepine days was 1.6% in Q1 of 2010, declining to 1.1% by Q4 of 2017 (p < 0.001). CONCLUSIONS Among persons 12-18 years old dispensed an opioid analgesic, receipt of ≥90 daily MME declined during the years 2010-2017, as did the percentage of adolescent opioid days that overlapped with benzodiazepines. More than half of the individuals who received extended-release opioid analgesics were identified as opioid naïve and, counter to guidelines, received products intended for opioid-tolerant individuals.
Collapse
Affiliation(s)
- William T Basco
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jenna L McCauley
- Department of Psychiatry and Behavioral Services, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jingwen Zhang
- Department of Medicine, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Justin E Marsden
- Department of Medicine, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Khosrow Heidari
- Blue Cross Blue Shield of South Carolina, Columbia, South Carolina, USA
| | - Patrick D Mauldin
- Department of Medicine, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sarah J Ball
- Department of Medicine, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
31
|
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
|
32
|
Basco WT, Ward RC, Taber DJ, Simpson KN, Gebregziabher M, Cina RA, McCauley JL, Lockett MA, Moran WP, Mauldin PD, Ball SJ. Patterns of dispensed opioids after tonsillectomy in children and adolescents in South Carolina, United States, 2010-2017. Int J Pediatr Otorhinolaryngol 2021; 143:110636. [PMID: 33548590 DOI: 10.1016/j.ijporl.2021.110636] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/12/2021] [Accepted: 01/22/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Tonsillectomy (with or without adenoidectomy) is a common pediatric surgical procedure requiring post-operative analgesia. Because of the respiratory depression effects of opioids, clinicians strive to limit the use of these drugs for analgesia post-tonsillectomy. The objective of this study was to identify demographic and medication use patterns predictive of persistent opioid dispensing (as a proxy for opioid use) to pediatric patients post-tonsillectomy. PATIENTS AND METHODS Retrospective cohort of South Carolina (USA) Medicaid-insured children and adolescents 0-18 years old without malignancy who had tonsillectomy in 2014-2017. We evaluated opioid dispensing pre-surgery and in the 30 days exposure period after hospital discharge. The main outcome, persistent opioid dispensing, was defined as any subject dispensed ≥1 opioid prescription 90-270 days after discharge. Group-based trajectory analyses described post-procedure opioid dispensing trajectories. RESULTS There were 11,578 subjects representing 12,063 tonsillectomy procedures. Few (3.5%) procedures were followed by persistent opioid dispensing. Any opioid dispensing during the exposure period was associated with an increased odds of persistent opioid dispensing status during the follow up period (OR 1.51 for 1-6 days of exposure and OR 1.65 for 7-30 days of opioid exposure), as was pre-procedure opioid dispensing, having >1 tonsillectomy procedure, and having complex chronic medical conditions. Group-based trajectory analyses identified 4 distinct patterns of post-discharge opioid dispensing. CONCLUSIONS Any opioid dispensing during the 30 days after tonsillectomy increased the odds of persistent opioid dispensing by > 50%. Multivariable and group-based trajectory analyses identified patient and procedure variables that correlate with persistent opioid dispensing, primarily driven by groups receiving pre-tonsillectomy opioids and a second group who experienced multiple episodes of tonsillectomy.
Collapse
Affiliation(s)
- William T Basco
- Pediatrics, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA.
| | - Ralph C Ward
- Public Health Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - David J Taber
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Kit N Simpson
- Health Administration and Policy, College of Health Professions, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Mulugeta Gebregziabher
- Public Health Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Robert A Cina
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Jenna L McCauley
- Psychiatry and Behavioral Sciences, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Mark A Lockett
- Surgery, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - William P Moran
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| | - Sarah J Ball
- Medicine, The Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC, 29425, USA
| |
Collapse
|
33
|
Basco WT, McCauley JL, Zhang J, Mauldin PD, Simpson KN, Heidari K, Marsden JE, Ball SJ. Trends in Dispensed Opioid Analgesic Prescriptions to Children in South Carolina: 2010-2017. Pediatrics 2021; 147:e20200649. [PMID: 33526605 PMCID: PMC7924141 DOI: 10.1542/peds.2020-0649] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite published declines in opioid prescribing and dispensing to children in the past decade, in few studies have researchers evaluated all children in 1 state or examined changes in mean daily opioid dispensed. In this study, we evaluated changes in the rate of dispensed opioid analgesics and the mean daily opioid dispensed to persons 0 to 18 years old in 1 state over an 8-year period. METHODS We identified opioid analgesics dispensed to children 0 to 18 years old between 2010 and 2017 using South Carolina prescription drug monitoring program data. We used generalized linear regression analyses to examine changes over time in the following: (1) rate of dispensed opioid prescriptions and (2) mean daily morphine milligram equivalents (MMEs) per prescription. RESULTS From the first quarter of 2010 to the end of the fourth quarter of 2017, the quarterly rate of opioids dispensed decreased from 18.68 prescriptions per 1000 state residents to 12.03 per 1000 residents (P < .0001). The largest declines were among the oldest individuals, such as the 41.2% decline among 18-year-olds. From 2010 through 2017, the mean daily MME dispensed declined by 7.6%, from 40.7 MMEs per day in 2010 to 37.6 MMEs per day in 2017 (P < .0001), but the decrease was limited to children 0 to 9 years old. CONCLUSIONS The rate of opioid analgesic prescriptions dispensed to children 0 to 18 years old in South Carolina declined by 35.6% over the years 2010-2017; however, the MME dispensed per day declined minimally, suggesting that more can be done to improve opioid prescribing and dispensing.
Collapse
Affiliation(s)
| | | | | | | | - Kit N Simpson
- Department of Healthcare Leadership and Management, College of Health Professions, Medical University of South Carolina, Charleston, South Carolina; and
| | - Khosrow Heidari
- BlueCross BlueShield of South Carolina, Columbia, South Carolina
| | | | | |
Collapse
|
34
|
Busse JW, Sadeghirad B, Oparin Y, Chen E, Goshua A, May C, Hong PJ, Agarwal A, Chang Y, Ross SA, Emary P, Florez ID, Noor ST, Yao W, Lok A, Ali SH, Craigie S, Couban R, Morgan RL, Culig K, Brar S, Akbari-Kelachayeh K, Pozdnyakov A, Shergill Y, Sivananthan L, Zihayat B, Das A, Guyatt GH. Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries : A Systematic Review and Network Meta-analysis of Randomized Trials. Ann Intern Med 2020; 173:730-738. [PMID: 32805127 DOI: 10.7326/m19-3601] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients and clinicians can choose from several treatment options to address acute pain from non-low back, musculoskeletal injuries. PURPOSE To assess the comparative effectiveness of outpatient treatments for acute pain from non-low back, musculoskeletal injuries by performing a network meta-analysis of randomized clinical trials (RCTs). DATA SOURCES MEDLINE, EMBASE, CINAHL, PEDro (Physiotherapy Evidence Database), and Cochrane Central Register of Controlled Trials to 2 January 2020. STUDY SELECTION Pairs of reviewers independently identified interventional RCTs that enrolled patients presenting with pain of up to 4 weeks' duration from non-low back, musculoskeletal injuries. DATA EXTRACTION Pairs of reviewers independently extracted data. Certainty of evidence was evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. DATA SYNTHESIS The 207 eligible studies included 32 959 participants and evaluated 45 therapies. Ninety-nine trials (48%) enrolled populations with diverse musculoskeletal injuries, 59 (29%) included patients with sprains, 13 (6%) with whiplash, and 11 (5%) with muscle strains; the remaining trials included various injuries ranging from nonsurgical fractures to contusions. Topical nonsteroidal anti-inflammatory agents (NSAIDs) proved to have the greatest net benefit, followed by oral NSAIDs and acetaminophen with or without diclofenac. Effects of these agents on pain were modest (around 1 cm on a 10-cm visual analogue scale, approximating the minimal important difference). Regarding opioids, compared with placebo, acetaminophen plus an opioid improved intermediate pain (1 to 7 days) but not immediate pain (≤2 hours), tramadol was ineffective, and opioids increased the risk for gastrointestinal and neurologic harms (all moderate-certainty evidence). LIMITATIONS Only English-language studies were included. The number of head-to-head comparisons was limited. CONCLUSION Topical NSAIDs, followed by oral NSAIDs and acetaminophen with or without diclofenac, showed the most convincing and attractive benefit-harm ratio for patients with acute pain from non-low back, musculoskeletal injuries. No opioid achieved benefit greater than that of NSAIDs, and opioids caused the most harms. PRIMARY FUNDING SOURCE National Safety Council. (PROSPERO: CRD42018094412).
Collapse
Affiliation(s)
- Jason W Busse
- McMaster University and Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada (J.W.B.)
| | - Behnam Sadeghirad
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Yvgeniy Oparin
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Eric Chen
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Anna Goshua
- Stanford University, Stanford, California (A.G.)
| | - Curtis May
- University of British Columbia, Vancouver, British Columbia, Canada (C.M.)
| | - Patrick J Hong
- University of Toronto, Toronto, Ontario, Canada (P.J.H., A.A., K.C.)
| | - Arnav Agarwal
- University of Toronto, Toronto, Ontario, Canada (P.J.H., A.A., K.C.)
| | - Yaping Chang
- McMaster University, Hamilton, and OrthoEvidence, Burlington, Ontario, Canada (Y.C.)
| | - Stephanie A Ross
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Peter Emary
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Ivan D Florez
- McMaster University, Hamilton, Ontario, Canada, and University of Antioquia, Medellin, Colombia (I.D.F.)
| | - Salmi T Noor
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - William Yao
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Annie Lok
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Syed Hussain Ali
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Samantha Craigie
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Rachel Couban
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Rebecca L Morgan
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Kayli Culig
- University of Toronto, Toronto, Ontario, Canada (P.J.H., A.A., K.C.)
| | - Sonia Brar
- University at Buffalo, Buffalo, New York (S.B.)
| | - Khashayar Akbari-Kelachayeh
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Alex Pozdnyakov
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Yaad Shergill
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | | | | | - Aninditee Das
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| |
Collapse
|
35
|
Robinson EJ, Watanabe BL, Brown LH. Ketamine for Prehospital Pain Management Does Not Prolong Emergency Department Length of Stay. PREHOSP EMERG CARE 2020; 25:753-760. [DOI: 10.1080/10903127.2020.1819493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
36
|
Vanolli K, Hugli O, Eidenbenz D, Suter MR, Pasquier M. Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service. Wilderness Environ Med 2020; 31:385-393. [PMID: 32912718 DOI: 10.1016/j.wem.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Although ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey. METHODS The survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy. RESULTS Ketamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg·kg-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1-2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor. CONCLUSIONS Ketamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.
Collapse
Affiliation(s)
- Katia Vanolli
- Medical School of the University of Lausanne, Lausanne, Switzerland
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - David Eidenbenz
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Marc R Suter
- Department of Anesthesia, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathieu Pasquier
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| |
Collapse
|