Prehospital pain management in children with traumatic injuries

Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine

BACKGROUND

More than half of all emergency department patients seek help for acute pain, which is usually of musculoskeletal origin. Acute pain is often inadequately treated even today, particularly in children and in older patients. In this study, we assess the potential role of regional anesthetic methods in improving the treatment of pain in the preclinical and clinical emergency setting.

METHODS

Pain-related reasons for admission were identified and quantified from emergency admission data. A structured literature search was carried out for clinical studies on the treatment of pain in the emergency setting, and a before-and-after comparison of the pain relief achieved with established vs. newer regional anesthetic methods was performed.

RESULTS

43% of emergency patients presented with acute musculoskeletal pain. The literature search yielded 3732 hits for screening; data on entity-specific pain therapy spectra were extracted from 153 studies and presented for the main pain regions. The degree of pain relief obtained through regional anesthetic procedures, on a nominal rating scale from 0 to 10, was 4 to 7 points for acute back and chest wall pain, >6 for shoulder pain, 5 to 7 for hand and forearm injuries, and >4 for hip fractures. These results were as good as, or better than, those obtained by analgesia/sedation with strong opioids.

CONCLUSION

Modern regional anesthetic techniques can improve acute pain management in the emergency department and, to some extent, in the pre-hospital setting as well. Pain relief with these techniques is quantifiably better than with strong opioids in some clinical situations; moreover, there is evidence of further advantages including process optimization and fewer complications. Data for comparative study remain scarce because of a lack of standardization.

Comparison of Professionally and Parentally Administered Analgesia Before Emergency Department Admission

BACKGROUND

Pediatric patients frequently present to emergency departments in pain.

AIM

A cross-sectional prospective study was conducted to investigate the prevalence of acute pain in children attending the ED and arriving by ambulance, as well as the initial ED management of pain. We describe pediatric pain management practices in the pediatric ED, as well as parental pain relief.

METHOD

Demographic data, medications, and type of transport to hospital were noted. Pain was assessed upon admission and 30 minutes after administration of analgesia. To standardize pain evaluations, only children aged 4 years or older were included in the study. A numeric rating scale was used to assess pain intensity.

RESULTS

The study group consisted of 124 patients. More than 80% of the patients suffered from trauma, injuries to the extremities were the most common cause of admission, and the patient population showed male predominance (62.1%). Over half of the patients (64.51%) were transported by ambulance. Analgesia was administered in 63.5% of the ambulance cases in contrast to only 13.3% of children brought by their parents. Treatment was significantly related to severity of pain.

CONCLUSIONS

Both medical emergency teams and parents administered prehospital analgesia insufficiently and without previous assessment. However, medical emergency teams used medications more often than parents. Analgesic therapy used in the emergency department resulted in significant pain reduction.

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.

Feasibility of patient-controlled analgesia (PCA) for rural and remote transfers

BACKGROUND

In rural Canada, the majority of prehospital care is provided by basic life support paramedics, who cannot administer opioids or parenteral analgesics. Patients requiring transfer to a higher level of care have limited options for pain control. We aim to determine if ambulance-based patient-controlled analgesia (PCA) is feasible during inter-facility transfers.

METHODS

This is a prospective non-consecutive cohort feasibility study conducted in the East Kootenay region of British Columbia from 2016 to 2020. Patients in acute pain from an illness or injury requiring an opioid and transfer to a higher level of care were offered PCA. The study used respiratory depression as a marker of safety, assessed if PCA during transport provided efficacious analgesia, measured satisfaction scores from patients and paramedics, and tracked adverse events.

RESULTS

84 patients received PCA. The majority had orthopaedic trauma and the average transfer time was 3 h 22 min. The average pain score at the start and end of the transfer was unchanged, at 4 out of 10. Patient and paramedic satisfaction scores at the end of the transfer were 4.6 and 4.7 out of 5, respectively. Three out of the 84 patients (3.6%) had desaturation episodes below or equal to 90% oxygen saturation; however, all resolved with supplemental oxygen.

INTERPRETATION

Ambulance-based PCA is feasible and has a high level of satisfaction among paramedics and patients. It has significant potential for inter-facility transport in rural regions in Canada where ambulances are staffed with paramedics who cannot administer opioids or other parenteral analgesics.

Analgesia in pediatric trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis

BACKGROUND

As pediatric patients are typically rare among helicopter emergency medical systems (HEMS), children might be at risk for oligo-analgesia due to the rescuer's lack of experience and the fear of side effects.

METHODS

In this retrospective analysis, data was obtained from the ÖAMTC HEMS digital database including 14 physician staffed helicopter bases in Austria over a 12-year timeframe. Primary missions involving pediatric trauma patients (< 15 years) not mechanically ventilated on-site were included. Analgesia was assessed and compared between the age groups 0-5, 6-10 and 11-14 years.

RESULTS

Of all flight missions, 8.2% were dedicated to children < 15 years. Analgetic drugs were administered in 31.4% of all primary missions (3874 of 12,324), wherefrom 2885 were injured and non-ventilated (0-5 yrs.: n = 443; 6-10 yrs.: n = 902; 11-14 yrs.: n = 1540). The majority of these patients (> 75%) suffered moderate to severe pain, justifying immediate analgesia. HEMS physicians typically chose a monotherapy with an opioid (n = 1277; 44.3%) or Esketamine (n = 1187; 41.1%) followed by the combination of both (n = 324; 11.2%). Opioid use increased (37.2% to 63.4%) and Esketamine use decreased (66.1% to 48.3%) in children < 6 vs. > 10 years. Esketamine was more often administered in extremity (57.3%) than in head (41.5%) or spine injuries (32.3%). An intravenous access was less often established in children < 6 years (74.3% vs. 90.8%; p < 0.001). Despite the use of potent analgesics, 396 missions (13.7%) were performed without technical monitoring. Particularly regarding patient data at handover in hospital, merely < 10% of all missions featured complete documentation. Therefore, sufficient evaluation of the efficacy of pain relief was not possible. Yet, by means of respiratory measures required during transport, severe side effects such as respiratory insufficiency, were barely noted.

CONCLUSIONS

In the physician-staffed HEMS setting, pediatric trauma patients liberally receive opioids and Esketamine for analgesia. With regard to severe respiratory insufficiency during transport, the application of these potent analgesics seems safe.

[Analgesia for trauma patients in emergency medicine]

Adequate analgesia is one of the most important measures of emergency care in addition to treatment of vital function disorders and, if indicated, should be promptly undertaken; however, a large proportion of emergency patients receive no or only inadequate pain therapy. The numeric rating scale (NRS) is recommended for pain assessment but is not applicable to every group of patients; therefore, vital signs and body language should be included in the assessment. Pain therapy should reduce the NPRS to <5 points. Ketamine and fentanyl, which have an especially rapid onset of action, and also morphine are suitable for analgesia in spontaneously breathing patients. Basic prerequisites for safe and effective analgesia by healthcare professionals are the use of adequate monitoring, the provision of well-defined emergency equipment, and the mastery of emergency procedures. In a structured competence system, paramedics and nursing personnel can perform safe and effective analgesia.

The assessment and management of thermal burn injuries in a UK ambulance service: a clinical audit

Background:

Although burn emergencies are infrequently encountered, the ambulance service is often the first point of contact for patients in these situations. It is therefore important that these potentially devastating injuries are managed in accordance with the evidence base. Appropriate assessment and management of these patients in the pre-hospital phase will have a significant impact upon their long-term outcomes, such as scarring cosmesis and functionality.

Aim and objectives:

This audit was conducted to determine if patients presenting to one UK ambulance service with thermal burn injuries were managed safely, effectively and in a timely manner. Areas highlighted for improvement will assist in directing future pre-hospital research and educational requirements. Epidemiological data will also be provided.

Results:

278 thermal burn incidents occurring from June 2017 to May 2018 (inclusive) were included in this audit. A larger proportion of burn patients were paediatrics who fell into the 0–10 age category, most burn patients were injured at a home address and only nine of the overall sample were major burns. Only 35% of patients received adequate cooling of their burns, an essential first aid intervention. The assessment of pain (87%) and provision of analgesia (75%) showed a higher compliance rate. However, only 54% had pain reassessed after analgesia. There was a near 100% compliance rate for patients being managed without hydrogel dressings and topical medicines.

Conclusion:

The results indicate several areas for improvement within the ambulance trust. Of importance is the application of basic first aid, such as cooling. It is important not only to improve education among staff but also to understand non-compliance. It should be acknowledged that assessment of pain and provision of analgesia demonstrated far higher compliance compared to current pre-hospital evidence. Several points for education and research have been identified.

Assessment of Pain Management During Interfacility Air Medical Transport of Intubated Patients

OBJECTIVE

The management of pain is an important component of care in the prehospital and transport setting. However, recent evidence suggests that pain control is infrequently achieved in these settings. The objective of the current study was to determine the proportion and frequency of opioid analgesia provided to intubated patients during interfacility transport by an air medical transport system.

METHODS

This was a health records review examining electronic records of intubated patients transported by Ornge from July 2015 to November 2015. Cases were identified using Ornge database, and intubated patients were selected based on the inclusion criteria. A standardized data extraction form was piloted and used by a single trained data extractor. The primary outcome was whether analgesia was provided. Secondary outcomes included the frequency of administration and dose adequacy of an opioid analgesia; the analgesic used; adverse events; and the impact of age, sex, past medical history of chronic pain, or reason for transfer on pain management.

RESULTS

Of the 500 potential patient transports, 448 met our inclusion criteria. Among the 448 patients, 295 (65.8%) were men, 327 (73.0%) received analgesia, and 211 (64.3%) received more than 1 dose during transport (median frequency of 2 doses, interquartile range = 1 to 3). The average transport time was 135 minutes, and repeated dosing (> 1 repeat dose) occurred primarily (45.5%) in transports of over 180 minutes. Fentanyl was the most commonly used analgesic (97.9%), and the most common dose was 50 µg (51.8%). Adverse events occurred in 8 patients (2.5%), most commonly new hypotension (mean arterial pressure < 65 mm Hg, n = 5). There was no significant difference in the administration of analgesia based on the patient's age or sex (68.0% of female patients and 75.6% of male patients received analgesia). Interestingly, only 30.8% of patients repatriated to their originating hospital received analgesia compared with 72.3% of patients undergoing their initial transfer to a higher level of care.

CONCLUSION

Seventy-three percent of intubated patients transported by Ornge received an opioid analgesic, most commonly fentanyl. We found no clinically relevant difference in the administration of analgesics based on age, sex, past medical history of chronic pain, or reason for transfer other than repatriation to the originating hospital.

Effects of the Introduction of Intranasal Fentanyl on Reduction of Pain Severity Score in Children: An Interrupted Time-Series Analysis

OBJECTIVES

Children are at risk of inadequate analgesia due to paramedics' inexperience in assessing children and challenges in administering analgesics when the patient is distressed and uncooperative. This study reports on the outcome of a change to practice guidelines that added intranasal fentanyl and intramuscular morphine within a large statewide ambulance service.

METHODS

This retrospective study included patients younger than 15 years treated by paramedics between January 2008 and December 2011. The primary outcome of interest was the proportion of patients having a 2/10 or greater reduction in pain severity score using an 11-point Verbal Numeric Rating Scale before and after the intervention. Segmented regression analysis was used to estimate the effect of the intervention over time. A multiple regression model calculated odds ratios with 95% confidence intervals.

RESULTS

A total of 92,378 children were transported by paramedics during the study period, with 9833 cases included in the analysis. The median age was 11 years; 61.6% were male. Before the intervention, 88.1% (n = 3114) of children receiving analgesia had a reduction of pain severity of 2 or more points, with 94.2% (n = 5933) achieving this benchmark after intervention (P < 0.0001). The odds of a reduction in pain of 2 or more points increased by 1.01 per month immediately before the intervention and 2.33 after intervention (<0.0001).

CONCLUSIONS

This large study of a system-wide clinical practice guideline change has demonstrated a significant improvement in the outcome of interest. However, a proportion of children with moderate to severe pain did not receive analgesia.

Low-dose methoxyflurane analgesia in adolescent patients with moderate-to-severe trauma pain: a subgroup analysis of the STOP! study

Introduction

The undertreatment of acute pain presents a significant challenge in the Emergency Department. This post hoc subgroup analysis of a previously reported randomized controlled UK study reports the efficacy and safety of low-dose methoxyflurane analgesia in treating adolescent patients with moderate-to-severe trauma pain.

Patients and methods

Three hundred patients (96 in the adolescent subgroup) aged ≥12 years requiring analgesia for acute trauma pain (pain score of 4-7 on the Numerical Rating Scale) at triage were randomized 1:1 to methoxyflurane (up to 6 mL) or placebo (normal saline), both administered using a Penthrox^® inhaler. The patient could request rescue medication (paracetamol/opioids) at any time. The primary endpoint was the change from baseline in visual analog scale (VAS) pain intensity.

Results

Mean VAS pain score for the adolescent subgroup at baseline was ~ 61 mm. Adjusted mean change in VAS pain intensity from baseline to 5, 10, 15, and 20 minutes was -24.5, -28.1, -31.6, and -31.7 mm for methoxyflurane and -14.6, -18.8, -19.2, and -23.7 mm for placebo, with a statistically significant treatment effect in favor of methoxyflurane overall across all four time points (-9.9 mm; 95% CI: -17.4, -2.4 mm; P=0.0104). Median time to first pain relief was significantly shorter with methoxyflurane (1 minute) than placebo (3 minutes, P<0.0001). Pain relief was reported within 1-10 inhalations in 95.7% of methoxyflurane-treated patients and 64.6% of placebo-treated patients. Rescue medication was requested by two (4.3%) methoxyflurane-treated patients and three (6.3%) placebo-treated patients. Over 95% of patients, physicians, and nurses rated methoxyflurane treatment as "Excellent", "Very Good" or "Good" compared with between 64% and 68% for placebo. The incidence of adverse events was higher with methoxyflurane (51%) than placebo (42%), mostly comprising mild/transient dizziness and headache.

Conclusion

This subgroup analysis shows that low-dose inhaled methoxyflurane is a rapid-acting and effective analgesic in adolescent patients presenting with moderate-to-severe trauma pain.

Trial registration

Clinicaltrials.gov identifier: NCT01420159, EudraCT number: 2011-000338-12.

Efficacy and safety of inhaled low-dose methoxyflurane for acute paediatric pain: A systematic review

Introduction

Undertreatment of acute, moderate-to-severe pain in children is common, due in part to barriers to the use of opioids. Low-dose methoxyflurane is an inhaled, non-opioid analgesic widely used in Australia and recently approved in Europe for the emergency relief of acute moderate-to-severe trauma pain in adults.

Methods

Using an integrative review framework, we conducted a literature analysis to examine the potential utility of methoxyflurane in children with acute pain. EMBASE®, MEDLINE® and PubMed were searched (criteria included ‘methoxyflurane’ ‘child*’ or ‘adolescent’ or ‘pediatr*’ or ‘paediatr*’) from January 2000 to October 2017, along with internet-based sources to identify relevant grey literature (no predefined search criteria). A series of investigative questions were developed regarding the safety and efficacy of methoxyflurane in this setting and addressed using evidence collated from the identified studies.

Results

Of 366 results from the literature searches, 6 clinical trials and observational studies were identified which explored the safety and/or efficacy of inhaled methoxyflurane in individuals < 18 years in either a clinical trial or observational study. All six studies concluded that methoxyflurane provides effective and rapid analgesia for paediatric acute moderate-to-severe pain. Methoxyflurane was well tolerated and associated with good levels of patient/healthcare provider satisfaction in this setting.

Conclusions

While large-scale studies are needed to better inform treatment approaches for paediatric use, inhaled methoxyflurane has potential to provide easy to administer, needle-free analgesia with a rapid onset and good safety profile.

S(+)-ketamine : Current trends in emergency and intensive care medicine

S(+)-ketamine, the pure dextrorotatory enantiomer of ketamine has been available for clinical use in analgesia and anesthesia for more than 25 years. The main effects are mediated by non-competitive inhibition of the N-methyl-D-aspartate (NMDA) receptor but S(+)-ketamine also interacts with opioid receptors, monoamine receptors, adenosine receptors and other purinergic receptors. Effects on α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, metabotropic glutamate receptors (mGluR) and L‑type calcium chanels have also been described. S(+)-ketamine stimulates the sympathetic nerve system, making it an ideal drug for analgosedation or induction of anesthesia in instable patients. In addition, the neuroprotective properties, bronchodilatory, antihyperalgesic or antiepileptic effects provide interesting therapeutic options. In this article we discuss the numerous effects of S(+)-ketamine under pharmacological and clinical aspects especially for typical indications in emergency medicine as well as intensive care.

Is caregiver refusal of analgesics a barrier to pediatric emergency pain management? A cross-sectional study in two Canadian centres

What is known about the topic?

Children’s pain in the emergency department (ED) continues to be under-recognized and sub-optimally managed.

What did this study ask?

We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED.

What did this study find?

Of the 743 children who presented to the ED with a painful condition, 408 (54.9%) were offered analgesia. If offered in the ED, analgesia was accepted by 91% (373/408) of the caregivers/children.

Why does this study matter to clinicians?

This study suggests that caregiver/child refusal of analgesia is a not a major barrier to optimal pain management and highlights the importance of ED personnel in encouraging adequate analgesia.

[Typical problems in pediatric emergencies: Possible solutions]

BACKGROUND

Pediatric emergencies are rare and challenging for health care providers, parents, and patients. The purpose of this article is to highlight typical difficulties in the treatment of pediatric patients and to discuss potential solutions.

MATERIALS AND METHODS

This article is based on a selective literature search using PubMed and the experience of the authors in the field of simulation and pediatric emergencies.

RESULTS

Inexperience with pediatric emergencies, uncertainty in technical skills, in the usage of pediatric equipment and in medication dosage as well as parental presence foster the perception of stress and potentially compromise the success of patient care. Beside implementation of simplified technical skill devices (e.g., intraosseous vascular access system, supraglottic airway devices, and alternative approaches for drug administration), there have been many efforts in recent years to improve patient safety. Tools for estimating body weight and precalculated drug-dosing charts have been implemented as well as standardized courses for guidelines, technical skills, and team-related skills have been established.

CONCLUSION

To improve patient safety, regular training and implementation of a sustainable safety culture are mandatory.