Evidence-based practice: best imaging practice in musculoskeletal disorders

Paracetamol, ketorolac, and morphine in post-trauma headache in emergency department: A double blind randomized clinical trial

Introduction:

Headache is one of the most common complaints of patients after head trauma. The aim of this study was the comparison of the analgesic effects of intravenous ketorolac, morphine, and paracetamol in patients with headache following head trauma.

Methods:

This clinical trial was performed on 105 referred patients to emergency unit with headache after head trauma. Patients were randomly divided into three groups of intravenous paracetamol (15 mg/kg in 100 mL normal saline), intravenous ketorolac (30 mg/kg in 100 mL normal saline), and intravenous morphine (0.1 mg/kg in 100 mL normal saline). Headache severity and side effects of drugs were assessed at baseline and 15, 30, and 60 min after intervention.

Results:

Headache severity score at baseline was similar among groups. After 15 min, headache severity score in paracetamol group was significantly lower than that in morphine and ketorolac groups (3.7 vs. 4.6 and 4.5, respectively). After 30 min, the score in paracetamol and ketorolac groups was significantly lower than that in morphine group (1.9 and 2.4 vs. 3.2, respectively). After 60 min, headache severity score in three groups was similar (1.6 in morphine and ketorolac groups and 1.5 in paracetamol group). The incidence of side effects in morphine group was significantly more than that in paracetamol and ketorolac groups.

Conclusion:

In emergency department, intravenous paracetamol and ketorolac obtain a faster and more effective onset compared with morphine for headache after head trauma.

The effect of pain management in reducing limb and spine radiography in stable traumatic patients admitted to the emergency department

Introduction

Musculoskeletal pain caused by trauma is one of the common complaints of patients referred to the emergency department. Due to the lack of a proper pain control protocol, doctors and nurses do not pay attention to pain, and physicians may tend to request too many radiographs, many of which will be unnecessary. We aimed to study the effect of pain management by fentanyl in reducing the number of radiographs, reducing hospital costs and increasing satisfaction in the patients on patients with isolated trauma in limbs and spine causing musculoskeletal pain.

Patients and methods

A cohort of patients who were referred to the fast-track emergency department with isolated trauma of the upper and lower limbs or spine and triage levels 3, 4 and 5, were visited twice by an emergency medicine resident – before and after application of a pain management protocol using intravenous fentanyl as the principle analgesic. The primary outcome measure was the reduction in the number of radiographs requested; secondary outcomes included alterations in pain levels and patient satisfaction.

Results

A total of 158 patients were included in the study. The median age was 27.5 years, three quarters were male and 20.88% had a positive history of opium addiction. The number and costs of diagnostic radiography significantly decreased after the administration of fentanyl (P < 0.0001), as did pain levels measured on visual analogue scale with a consequent increase in patient satisfaction. There were only six complications resulting from fentanyl administration which were mild and transient. Follow-up after 24–72 h, revealed no missed fractures.

Conclusions

The administration of fentanyl as a strong analgesic as part of an emergency department pain management protocol for trauma patients can be performed with limited minor complications; it can reduce the number of unnecessary X-rays performed, exposure to ionizing radiation and hospital costs as well as improving patient satisfaction without missing fractures.