Evidence-Based Guidelines for Prehospital Pain Management: Recommendations

Intravenous Acetaminophen Versus Ketorolac for Prehospital Analgesia: A Retrospective Data Review

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.

Out-of-Hospital Intranasal Ketamine as an Adjunct to Fentanyl for the Treatment of Acute Traumatic Pain: A Randomized Clinical Trial

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.

Achieving Equity in EMS Care and Patient Outcomes Through Quality Management Systems: A Position Statement

Improving health and safety in our communities requires deliberate focus and commitment to equity. Inequities are differences in access, treatment, and outcomes between individuals and across populations that are systemic, avoidable, and unjust. Within health care in general, and Emergency Medical Services (EMS) in particular, there are demonstrated inequities in the quality of care provided to patients based on a number of characteristics linked to discrimination, exclusion, or bias. Given the critical role that EMS plays within the health care system, it is imperative that EMS systems reduce inequities by delivering evidence-based, high-quality care for the communities and patients we serve. To achieve equity in EMS care delivery and patient outcomes, the National Association of EMS Physicians recommends that EMS systems and agencies:make health equity a strategic priority and commit to improving equity at all levels.assess and monitor clinical and safety quality measures through the lens of inequities as an integrated part of the quality management process.ensure that data elements are structured to enable equity analysis at every level and routinely evaluate data for limitations hindering equity analysis and improvement.involve patients and community stakeholders in determining data ownership and stewardship to ensure its ongoing evolution and fitness for use for measuring care inequities.address biases as they translate into the quality of care and standards of respect for patients.pursue equity through a framework rooted in the principles of improvement science.

Short-term outcomes of prehospital opioid pain management for older adults with fall-related injury

BACKGROUND

Opioids are recommended for pain management in patients being cared for and transported by emergency medical services, but no specific guidelines exist for older adults with fall-related injury. Prior research suggests prehospital opioid administration can effectively manage pain in older adults, but less is known about safety in this population. We compared short-term safety outcomes, including delirium, disposition, and length of stay, among older adults with fall-related injury according to whether they received prehospital opioid analgesia.

METHODS

We linked Medicare claims data with prehospital patient care reports for older adults (≥65) with fall-related injury in Illinois between January 1, 2014 and December 31, 2015. We used weighted regression models (logistic, multinomial logistic, and Poisson) to assess the association between prehospital opioid analgesia and incidence of inpatient delirium, hospital disposition, and length of stay.

RESULTS

Of 28,150 included older adults, 3% received prehospital opioids. Patients receiving prehospital opioids (vs. no prehospital opioids) were less likely to be discharged home from the emergency department (adjusted probability = 0.30 [95% CI: 0.25, 0.34] vs. 0.47 [95% CI: 0.46, 0.48]), more likely to be discharged to a non-home setting after an inpatient admission (adjusted probability = 0.43 [95% CI: 0.39, 0.48] vs. 0.30 [95% CI: 0.30, 0.31]), had inpatient length of stay 0.4 days shorter (p < 0.001) and ICU length of stay 0.7 days shorter (p = 0.045). Incidence of delirium did not vary between treatment and control groups.

CONCLUSIONS

Few older adults receive opioid analgesia in the prehospital setting. Prehospital opioid analgesia may be associated with hospital disposition and length of stay for older adults with fall-related injury. However, our findings do not provide evidence of an association with inpatient delirium. These findings should be considered when developing guidelines for prehospital pain management specific to the older adult population.

Evaluation of Nonintubated Analgesia Practices in Critical Care Transport

OBJECTIVE

Current analgesia recommendations in the prehospital setting are not specific to critical care transport. Variation exists in the recommended agent and dosing strategies. Furthermore, there is a paucity of literature evaluating benzodiazepine and opiate coadministration, which may place patients at risk for respiratory decompensation.

METHODS

This was a retrospective chart review of nonintubated adult critical care transport patients between July 1, 2020, and July 1, 2022, who received fentanyl or ketamine during transport. The primary outcome was the proportion of patients oversedated. The secondary outcomes were characterization of analgesic medication use during transport, the percentage of patients coadministered benzodiazepines, naloxone administration, and escalation of respiratory intervention.

RESULTS

Three hundred seventy-six patients were administered fentanyl or ketamine during transport. Eleven patients were oversedated. Three hundred twenty-four patients received fentanyl monotherapy, and 52 received combination therapy. Patients who received benzodiazepines had higher odds of oversedation (odds ratio = 5.75; 95% confidence interval, 1.6-20.7). Two hundred thirty-six patients required an escalation in respiratory support, most commonly an increase from room air to nasal cannula. No patients had naloxone administered.

CONCLUSION

The rate of oversedation of nonintubated adult critical care transport patients receiving fentanyl or ketamine is low. Coadministration of benzodiazepines increases the risk of oversedation.

A Comparison of Prehospital Pediatric Analgesic Use of Ketamine and Opioids

OBJECTIVE/INTRODUCTION

Ketamine is an opioid-alternative used for analgesia in the prehospital setting. There are knowledge gaps regarding its use during emergency medical services (EMS) encounters for pediatric patients. Our objective was to compare pain reduction, adverse events, and prehospital deaths between ketamine and opioids when used for analgesia administered by any route among pediatric patients.

METHODS

This was a retrospective review of 9-1-1 EMS records of injured pediatric patients (≤17 years of age) who received ketamine or opioids for analgesia using the ESO Data Collaborative (calendar years 2019-2020). We excluded interfacility transfers, patients receiving both medications, those with EMS clinician impressions indicating behavioral disorders, and those who received medication to facilitate advanced airway placement. EMS narrative review was performed to confirm ketamine use was for analgesia and to identify any unplanned airway placements. We assessed pain score reduction (0-10 ordinal scale) and clinician-documented patient response (improved, unchanged, worsened, unknown). Adverse events were defined as change in vital signs (GCS, SBP, RR, SpO2), bag valve mask ventilation alone, or death. Descriptive statistics were calculated to compare outcomes between groups.

RESULTS

Overall, 9,223 patients were included, 190 (2.1%) received ketamine and 9,033 (97.9%) received opioids. Mean age in years was 12.8 [SD 4.0] for ketamine and 12.7 [SD 4.0] for opioids. Patients in both groups experienced pain reduction, and more patients receiving ketamine had EMS clinician reported improvement (93.2% vs. 87.9%, p = 0.03). Ketamine was associated with a greater average reduction in pain score than opioids (mean difference: -4.4 [SD 3.5], and -3.1 [SD 2.8], p < 0.001). Adverse events were rare with few patients receiving ventilatory support following the use of ketamine or opioids, (0, [SD 0.0%] vs. 6 [SD 0.1%], p = 1). There were no unplanned airway placements or prehospital deaths identified.

CONCLUSION

We identified similar high rates of pain reduction and rare adverse events among pediatric patients who received ketamine or opioids. A greater pain reduction was noted among patients administered ketamine. Intubation as a result of medication administration did not occur and need for ventilatory assistance was rare.

Evidence-Based Guidelines for Prehospital Pain Management: Literature and Methods

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.

Recommendations for Improving the Quality of Prehospital Evidence-Based Guidelines

Evidence-based guidelines that provide recommendations for clinical care or operations are increasingly being published to inform the EMS community. The quality of evidence evaluation and methodological rigor undertaken to develop and publish these recommendations vary. This can negatively affect dissemination, education, and implementation efforts. Guideline developers and end users could be better informed by efforts across medical specialties to improve the quality of guidelines, including the use of specific criteria that have been identified within the highest quality guidelines. In this special contribution, we aim to describe the current state of published guidelines available to the EMS community informed by two recent systematic reviews of existing prehospital evidenced based guidelines (EBGs). We further aim to provide a description of key elements of EBGs, methods that can be used to assess their quality, and concrete recommendations for guideline developers to improve the quality of evidence evaluation, guideline development, and reporting. Finally, we outline six key recommendations for improving prehospital EBGs, informed by systematic reviews of prehospital guidelines performed by the Prehospital Guidelines Consortium.

Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children

BACKGROUND

Treatment with analgesics for injured children is often not provided or delayed during prehospital transport.

OBJECTIVE

Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children.

METHODS

We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids.

RESULTS

We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2-1.2) and 0.4 (95% CI 0.2-1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids.

CONCLUSIONS

There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.

Transport of the patient with trauma: a narrative review

Trauma and injury place a significant burden on healthcare systems. In most high-income countries, well-developed acute pre-hospital and trauma care systems have been established. In Europe, mobile physician-staffed medical teams are available for the most severely injured patients and apply a wide variety of lifesaving interventions at the same time as ensuring patient comfort. In trauma systems providing pre-hospital care, medical interventions are performed earlier in the patient journey and do not affect time to definite care. The mode of transport from the accident scene depends on the organisation of the healthcare system and the level of hospital care to which the patient is transported. This varies from 'scoop and run' to a basic community care setting, to advanced helicopter emergency medical service transport to a level 4 trauma centre. Secondary transport of trauma patients to a higher level of care should be avoided and may lead to a delay in definitive care. Critically injured patients must be accompanied by at least two healthcare professionals, one of whom must be skilled in cardiopulmonary resuscitation and advanced airway management techniques. Ideally, the standard of care provided during transport, including the level of monitoring, should mirror hospital care. Pre-hospital care focuses on the critical care patient, but the majority of injured patients need only close observation and pain management during transport. Providing comfort and preventing additional injury is the responsibility of the whole transport team.

Patient Demographics Are Associated with Differences in Prehospital Pain Management among Trauma Patients

OBJECTIVE

Disparities have been observed in the treatment of pain in emergency department patients. However, few studies have evaluated such disparities in emergency medical services (EMS). We describe pain medication administration for trauma indications in an urban EMS system and how it varies with patient demographics.

METHODS

We performed a retrospective review of the electronic medical records of adult patients transported for isolated trauma (without accompanying medical complaint) from 1/1/18 to 6/30/2020 by a third service EMS agency in a major United States metropolitan area. We performed descriptive statistics on epidemiology, type of pain medications administered, and pain scores. Kruskall-Wallis and chi-square or Fisher's exact tests were used to compare continuous and categorical variables, respectively. We constructed a logistic regression model to estimate the odds of nontreatment of pain by age, race, sex, transport interval, pain score, and Glasgow Coma Scale (GCS) score for patients with pain scores of at least four on a one to ten scale, the threshold for pain treatment per the EMS protocol.

RESULTS

Of 32,463 EMS patients with traumatic injuries included in the analysis, 40% (12,881/32,463) were African American, 50% (16,284/32,463) were female, the median age was 27 years (IQR 45-64), and the median initial pain score was 5 (IQR 2-8). Fifteen percent (4,989/32,463) received any analgesic. Initial pain scores were significantly higher for African American and female patients. African American patients were less likely to receive analgesia compared to White and Hispanic patients (19% versus 25% and 23%, respectively, p < 0.0001). Adjusting for age, pain score, transport interval, and GCS, African American compared to White, and female compared to male patients were less likely to be treated for pain, OR 1.59 (95% CI 1.47-1.72) and OR 1.20 (95% CI 1.11-1.28), respectively.

CONCLUSION

Among patients with isolated traumatic injuries treated in a single, urban EMS system, African American and female patients were less likely to receive analgesia than White or male patients. Analgesics were given to a small percentage of patients who were eligible for treatment by protocol, and intravenous opioids were used in the vast majority patients who received treatment.

Pain Management in a Prehospital Emergency Setting: A Retrospective Observational Study

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.

Disparities in Prehospital Non-Traumatic Pain Management

INTRODUCTION

While prior research has identified racial disparities in prehospital analgesia for traumatic pain, little is known about non-traumatic pain. Using a national prehospital dataset, we sought to evaluate for racial and ethnic disparities in analgesia given by EMS for non-traumatic pain.

METHODS

We analyzed the 2018 and 2019 data from the ESO Data Collaborative, a collection of de-identified prehospital electronic health records from nearly 1,300 participating EMS agencies in the US. We included all transported, adult, non-traumatic encounters with a primary or secondary impression of a pain complaint, and we stratified encounters based on race and ethnicity as recorded by the EMS clinicians. We performed a mixed model analysis, modeling EMS agency as a random intercept and adjusting for age, sex, pain location, level of service, location of incident, and highest pain score. With non-Hispanic White patients as the reference group, we then evaluated the association between race/ethnicity and receiving any pain medication (acetaminophen, non-steroidal anti-inflammatories, or opioids), receiving opioid pain medication, and receiving pain medication within 20 minutes of EMS arrival.

RESULTS

We included 1,035,486 patients; 67.5% non-Hispanic White, 26.8% Black, 4.9% Hispanic, 0.5% Asian, 0.1% Native Hawaiian or Other Pacific Islander, and 0.2% American Indian or Alaska Native patients. 4.7% of patients received pain medications. Compared to White patients (5.1%), Black patients were less likely to receive pain medication (3.3%, aOR 0.7; 95% CI 0.7-0.7) and Hispanics were more likely to receive pain medication (7.6%, aOR 1.5; 95% CI 1.4-1.6). Black patients were also less likely to receive opioids (1.8% for Black v 3.0% for White, aOR 0.7; 95% CI 0.6-0.7), while Hispanic patients were more likely to receive opioids (4.9%, aOR 1.4; 95% CI 1.3-1.5). The odds of receiving pain medication within 20 minutes was lower for Black patients (aOR 0.9; 95% CI 0.8-0.95) but no different for Hispanic patients (aOR 1.0; 95% CI 0.9-1.1), when compared to White patients.

CONCLUSION

Pain medication administration is uncommon for non-traumatic pain complaints. While Black patients were less likely than White patients to receive pain medications and receive pain medication within 20 minutes, Hispanics were more likely to receive pain medications.