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Watkins PM, Hill AM, Tohira H, Brink D, Finn J, Buzzacott P. Epidemiology of ambulance-attended adults who fell in Western Australia 2015 - 2021: An increasing incidence in an ageing population. Injury 2023; 54:111035. [PMID: 37777369 DOI: 10.1016/j.injury.2023.111035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 08/29/2023] [Accepted: 09/08/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Emergency Medical Services (EMS) are attending an increasing number of adults who fall. This study aimed to describe the incidence, patient characteristics, treatments and disposition of ambulance attended patients who fell in Western Australia (WA). METHODS An ordinal logistic regression (using STATA) was conducted in this retrospective cohort study, analysing predictors of lower compared to higher transport urgency levels. Participants were adults ( ≥ 18 years) who fell and required ambulance attendance in WA between 1st January 2015 - 31st December 2021. RESULTS A total of 188,720 patients (female = 107,811, 57 %) were attended by ambulances after falls, (median age = 80 years [IQR 67-87]). The age-standardized incidence rate of ambulance attended falls increased from 115 cases/100,000 person-years to 161 cases/100,000 person-years between 2015 and 2021. A total of 89,140 (47 %) patients had an injury recorded by paramedics, most often lacerations or suspected fractures. The electronic patient care record showed, 50,044 (26.5 %) patients received medication and 30,954 (16.4 %) patients received other intervention, e.g., ECG. A total of 148,050 (78 %) patients were transported to hospital with the following urgency levels: 2,371 (2 %) via urgency one; 27,882 (19 %) via urgency two, 93,447 (63 %) via urgency three and 22,584 (15 %) via urgency four and five ( < 1 % unknown urgency). Positive predictors of lower level transport urgency to hospital included being female and older than 65 years of age. CONCLUSION Older, female patients had higher odds of being transported via a lower urgency, with 50 % of this cohort transported via urgency three. While 19 % of patients were attended via a Priority one, only 1 % were transported to hospital via urgency one. The incidence rate of falls requiring ambulance attendance has increased over time, increasing the demand placed on EMS annually.
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Affiliation(s)
- Paige M Watkins
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Australia.
| | - Anne-Marie Hill
- School of Allied Health, University of Western Australia, Perth, Australia
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Australia; Discipline of Emergency Medicine, Medical School, The University of Western Australia, Perth, Australia
| | - Deon Brink
- St John Western Australia, Belmont, Australia
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Australia; St John Western Australia, Belmont, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Buzzacott
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), Curtin School of Nursing, Curtin University, Perth, Australia
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2
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The prehospital management of ambulance-attended adults who fell: A scoping review. Australas Emerg Care 2023; 26:45-53. [PMID: 35909044 DOI: 10.1016/j.auec.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The ageing population is requiring more ambulance attendances for falls. This scoping review aimed to map and synthesise the evidence for the prehospital management of Emergency Medical Services (EMS) attended adult patients who fall. METHODS The Joanna Briggs Institute methods for scoping reviews were used. Six databases were searched (Medline, Scopus, CINAHL, Cochrane, EMBASE, ProQuest), 1st August 2021. Included sources reported: ambulance attended (context), adults who fell (population), injuries, interventions or disposition data (concept). Data were narratively synthesised. RESULTS One-hundred and fifteen research sources met the inclusion criteria. Detailed information describing prehospital delivered EMS interventions, transport decisions and alternative care pathways was limited. Overall, adults< 65 years were less likely than older adults to be attended repeatedly and/or not transported. Being male, falling from height and sustaining severe injuries were associated with transport to major trauma centres. Older females, falling from standing/low height with minor injuries were less likely to be transported to major trauma centres. CONCLUSION The relationship between patient characteristics, falls and resulting injuries were well described in the literature. Other evidence about EMS management in prehospital settings was limited. Further research regarding prehospital interventions, transport decisions and alternative care pathways in the prehospital setting is recommended.
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Kingston M, Jones J, Black S, Evans B, Ford S, Foster T, Goodacre S, Jones ML, Jones S, Keen L, Longo M, Lyons RA, Pallister I, Rees N, Siriwardena AN, Watkins A, Williams J, Wilson H, Snooks H. Clinical and cost-effectiveness of paramedic administered fascia iliaca compartment block for emergency hip fracture (RAPID 2)-protocol for an individually randomised parallel-group trial. Trials 2022; 23:677. [PMID: 35978361 PMCID: PMC9385096 DOI: 10.1186/s13063-022-06522-3] [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: 05/31/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background Approximately 75,000 people fracture a hip each year in the UK. This painful injury can be devastating—with a high associated mortality rate—and survivors likely to be more dependent and less mobile. Pain relief at the scene of injury is known to be inadequate. Intravenous morphine is usually given by paramedics, but opioids are less effective for dynamic pain and can cause serious side effects, including nausea, constipation, delirium and respiratory depression. These may delay surgery, require further treatment and worsen patient outcomes. We completed a feasibility study of paramedic-provided fascia iliaca compartment block (FICB), testing the intervention, trial methods and data collection. The study (RAPID) demonstrated that a full trial was feasible. In this subsequent study, we aim to test safety, clinical and cost-effectiveness of paramedic-provided FICB as pain relief to patients with suspected hip fracture in the prehospital environment. Methods We will conduct a pragmatic multi-centre individually randomised parallel-group trial, with a 1:1 allocation between usual care (control) and FICB (intervention). Hospital clinicians in five sites (paired ambulance services and receiving hospitals) in England and Wales will train 220 paramedics to administer FICB. The primary outcome is change in pain score from pre-randomisation to arrival at the emergency department. One thousand four hundred patients are required to find a clinically important difference between trial arms in the primary outcome (standardised statistical effect ~ 0.2; 90% power, 5% significance). We will use NHS Digital (England) and the SAIL (Secure Anonymised Information Linkage) databank (Wales) to follow up patient outcomes using routine anonymised linked data in an efficient study design, and questionnaires to capture patient-reported outcomes at 1 and 4 months. Secondary outcomes include mortality, length of hospital stay, job cycle time, prehospital medications including morphine, presence of hip fracture, satisfaction, mobility, and NHS costs. We will assess safety by monitoring serious adverse events (SAEs). Discussion The trial will help to determine whether paramedic administered FICB is a safe, clinically and cost-effective treatment for suspected hip fracture in the pre-hospital setting. Impact will be shown if and when clinical guidelines either recommend or reject the use of FICB in routine practice in this context. Trial registration ISRCTN15831813. Registered on 22 September 2021.
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Affiliation(s)
| | | | - Sarah Black
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | | | - Simon Ford
- Swansea Bay University Health Board, Port Talbot, UK
| | - Theresa Foster
- East of England Ambulance Service NHS Trust, Melbourn, UK
| | | | | | | | - Leigh Keen
- Welsh Ambulance Services NHS Trust, St Asaph, UK
| | | | | | - Ian Pallister
- Swansea Bay University Health Board, Port Talbot, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, St Asaph, UK
| | | | | | - Julia Williams
- South East Coast Ambulance Services NHS Foundation Trust, Crawley, UK
| | - Helen Wilson
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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4
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Davis S, Olaussen A, Bowles KA, Shannon B. Review article: Paramedic pain management of femur fractures in the prehospital setting: A systematic review. Emerg Med Australas 2021; 33:601-609. [PMID: 33982421 DOI: 10.1111/1742-6723.13793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 04/13/2021] [Accepted: 04/20/2021] [Indexed: 01/05/2023]
Abstract
Femur shaft and neck of femur (NOF) fractures are often undertreated in the prehospital setting. These injuries can present unique clinical and logistical concerns in the prehospital setting. This systematic review aimed to investigate paramedic prehospital pain management of patients who had suffered NOF or femur fractures, and to investigate which interventions are effective. A systematic review was conducted in line with Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines. Four databases were searched from inception date 23 March 2020. Articles were independently reviewed by two authors and conflicts resolved by a third author, followed by a hand search of the included reference lists. References were included if they addressed paramedic interventions for NOF or femur shaft fractures. Outcomes of interest were the effectiveness and complications of different modalities administered by paramedics. The search yielded 6868 articles, of which 19 met the final inclusion criteria. Studies investigated a variety of interventions including traction splints, intravenous (IV) analgesia and alternative analgesic options. Traction splinting and IV analgesia were consistently reported as underutilised. Alternative analgesics such as auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and fascia iliaca compartment block were found to be effective techniques that could be safely and competently employed by paramedics, reducing pain for patients with limited adverse events. NOF and femur shaft fractures are an undertreated injury in the prehospital setting. Traction splinting and IV analgesia remain the traditional methodologies of treatment for these injuries; however, there are alternatives such as TENS, auricular acupressure and fascia iliaca compartment block that appear to be emerging as safe and effective options for the prehospital setting.
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Affiliation(s)
- Samantha Davis
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred, Melbourne, Victoria, Australia.,Emergency Department, Northeast Health Wangaratta, Wangaratta, Victoria, Australia
| | - Kelly-Ann Bowles
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Brendan Shannon
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
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5
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Hachimi-Idrissi S, Coffey F, Hautz WE, Leach R, Sauter TC, Sforzi I, Dobias V. Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment. Intern Emerg Med 2020; 15:1125-1139. [PMID: 32930965 DOI: 10.1007/s11739-020-02477-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
Pain management is a vital component of patient care, particularly in the emergency setting. Pain can hinder the opportunities to treat and manage pain-causing conditions and remains one of the primary reasons patients seek emergency medical care, yet despite this, pain often remains under-acknowledged, under-assessed and undertreated. Despite the importance of effective management of acute pain, there are currently no well-defined emergency medicine guidelines at a European level to support healthcare professionals in achieving this goal. The European Society for Emergency Medicine (EUSEM) identified this as a significant unmet requirement, for improving day-to-day patient management and for providing guidance to trainees and non-emergency medicine physicians. Under the auspices of EUSEM, a programme-the European Pain Initiative-was launched with the aim of providing information, advice and guidance on pain management in pre-hospital and emergency department settings. Search terms were developed to search MEDLINE, Cochrane database, Google Scholar and EMBASE online databases to return English language articles published in the last 10 years. A working package of reference materials was evaluated against inclusion and exclusion criteria and levels of evidence ascribed. A short survey was developed by the European Pain Initiative Steering Committee for completion by EUSEM members to evaluate actual clinical practice. A working document of > 800 publications was identified for further review and evaluation against agreed criteria. Some further publications were included by the Steering Committee to explore older literature for long-established analgesics, or newly emergent literature that was considered important for inclusion but was identified as the guideline development was underway. This article provides the methodology used to inform the guidelines, including survey results of EUSEM members on assessment and treatment of acute pain. A companion manuscript in this issue presents an evidence-based review and recommendations for individualised evaluation of acute pain in patients in emergency settings.
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Affiliation(s)
- Saïd Hachimi-Idrissi
- Department of Emergency Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - Frank Coffey
- Nottingham University Hospitals' NHS Trust, Nottingham, UK
| | - Wolf E Hautz
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
| | - Robert Leach
- Department of Emergency Medicine, Centre Hospitalier de Wallonie Picarde, Tournai, Belgium
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, Switzerland
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Fabbri A, Ruggiano G, Garcia Collado S, Ricard-Hibon A, Restelli U, Sbrana G, Marinangeli F, Farina A, Coffey F. Role of Inhaled Methoxyflurane in the Management of Acute Trauma Pain. J Pain Res 2020; 13:1547-1555. [PMID: 32612382 PMCID: PMC7323816 DOI: 10.2147/jpr.s252222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/06/2020] [Indexed: 11/23/2022] Open
Abstract
Adequate treatment of trauma pain is an integral part of the management of trauma patients, not just for ethical reasons but also because undertreated pain can lead to increased morbidities and worse long-term outcomes. Trauma pain management presents challenges in the pre-hospital setting, particularly in adverse or hostile environments as well as in busy emergency departments (EDs). Inhaled methoxyflurane, administered at analgesic doses via a disposable inhaler, has recently become available in Europe for the emergency treatment of moderate to severe pain in conscious adult trauma patients. A growing body of evidence demonstrates that inhaled methoxyflurane is well tolerated and effective in providing a rapid onset of analgesia. In this paper, we discuss the rationale for methoxyflurane use in trauma pain management, data from clinical trials recently conducted in Europe, its efficacy and safety profile compared to current standard treatments, its place in therapy and organizational impact. We conclude that inhaled methoxyflurane represents an effective treatment option in the different settings where trauma patients require rapid and flexible pain resolution, with potential organizational advantages.
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Affiliation(s)
- Andrea Fabbri
- Department of Emergency Medicine, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Germana Ruggiano
- Emergency Medicine Department, Santa Maria Annunziata Hospital, Florence, Italy
| | | | - Agnes Ricard-Hibon
- Service SAMU-SMUR-SAU, GHT Nord Ouest Vexin Val d’Oise, Pontoise95, France
| | - Umberto Restelli
- Center for Health Economics, Social and Health Care Management, LIUC - Università Cattaneo, Castellanza, VA, Italy
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Giovanni Sbrana
- Anaesthesia, Intensive Care, Emergency Medicine, Grosseto HEMS, ASL Toscana Sud Est, Grosseto, Italy
| | - Franco Marinangeli
- Department of Anesthesiology and Intensive Care, University of L’Aquila, L’Aquila, Italy
| | - Alberto Farina
- Medical Affairs Department, Mundipharma Pharmaceuticals Srl, Milan, Italy
| | - Frank Coffey
- DREEAM - Department of Research and Education in Emergency Medicine Acute Medicine and Major Trauma, Nottingham University Hospitals’ NHS Trust, Nottingham, UK
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Evans BA, Brown A, Fegan G, Ford S, Guy K, Jones J, Jones S, Keen L, Khanom A, Longo M, Pallister I, Rees N, Russell IT, Seagrove AC, Watkins A, Snooks H. Is fascia iliaca compartment block administered by paramedics for suspected hip fracture acceptable to patients? A qualitative study. BMJ Open 2019; 9:e033398. [PMID: 31862740 PMCID: PMC6937129 DOI: 10.1136/bmjopen-2019-033398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/15/2019] [Accepted: 10/23/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To explore patients' experience of receiving pain relief injection for suspected hip fracture from paramedics at the location of the injury. DESIGN Qualitative interviews within a feasibility trial about an alternative to routine prehospital pain management for patients with suspected hip fracture. SETTING Patients treated by paramedics in the catchment area of one emergency department in South Wales. PARTICIPANTS Six patients and one carer of a patient who received fascia iliaca compartment block (FICB). INTERVENTION FICB administered to patients with suspected hip fracture by trained paramedics. We randomly allocated eligible patients to FICB-a local anaesthetic injection directly into the hip region-or usual care-most commonly morphine-using audited scratch cards. OUTCOMES Acceptability and experience of receiving FICB, assessed through interview data. We audio-recorded, with participants' consent, and conducted thematic analysis of interview transcripts. The analysis team comprised two researchers, one paramedic and one lay member. RESULTS Patients had little or no memory of being offered, consenting to or receiving FICB. They recalled the reassuring manner and high quality of care received. They accepted FICB without question. Partial or confused memory characterised experience of subsequent hospital care until surgery. They said their priorities when calling for emergency help were to receive effective care. After hospital treatment, they wanted to regain their health and mobility and resume the quality of life they experienced before their injury. CONCLUSIONS This study did not raise any concerns about the acceptability of FICB administered at the scene of injury by paramedics to people with suspected hip fracture. It adds to existing evidence about patient and carer experience of on-scene care for people with suspected hip fracture. Further research is needed to assess safety, effectiveness and cost effectiveness of this health technology in a new setting. TRIAL REGISTRATION NUMBER ISRCTN60065373.
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Affiliation(s)
| | - Alan Brown
- Public contributor c/o Swansea University, Swansea, UK
| | - Greg Fegan
- Medical School, Swansea University, Swansea, UK
| | - Simon Ford
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
| | - Katy Guy
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
| | - Jenna Jones
- Medical School, Swansea University, Swansea, UK
| | - Sian Jones
- Public contributor c/o Swansea University, Swansea, UK
| | - Leigh Keen
- Welsh Ambulance Services NHS Trust, Swansea, UK
| | | | - Mirella Longo
- Marie Curie Palliative Care Research Centre, Cardiff University School of Medicine, Cardiff, UK
| | - Ian Pallister
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, Swansea, UK
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Jones JK, Evans BA, Fegan G, Ford S, Guy K, Jones S, Keen L, Khanom A, Longo M, Pallister I, Rees N, Russell IT, Seagrove AC, Watkins A, Snooks HA. Rapid Analgesia for Prehospital hip Disruption (RAPID): findings from a randomised feasibility study. Pilot Feasibility Stud 2019; 5:77. [PMID: 31210961 PMCID: PMC6560881 DOI: 10.1186/s40814-019-0454-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 05/06/2019] [Indexed: 11/29/2022] Open
Abstract
Background In managing hip fracture, effective pain relief before admission to hospital is difficult without risking side effects. Although emergency departments routinely use fascia iliaca compartment block (FICB), there has been little evaluation of its use by paramedics before hospital admission. We aimed to assess whether a multi-centre randomised trial to evaluate FICB was feasible. Methods Volunteer paramedics used scratchcards to allocate patients with hip fracture at random between FICB and pain relief as usual. Primary outcomes were mortality and quality of life. We also measured adverse events, costs, final diagnosis, length of stay in hospital, pain scores and quality of care and collected qualitative data about acceptability to patients in interviews, and paramedics in focus groups. We pre-specified criteria for deciding whether to progress to a fully powered trial based on the recruitment of paramedics and patients, delivery of FICB, retrieval of outcome data, safety, acceptability, and diagnostic accuracy of hip fracture. Results We effectively met all progression criteria: we recruited 19 paramedics who randomly allocated 71 patients between trial arms between 28 June 2016 and 31 July 2017; 57 (31 experimental arm, 26 usual care arm, 80% overall) retrospectively consented to follow-up. Just over half (17/31) of experimental participants received FICB; all others had contraindications, including nine taking anticoagulants. Four of the 31 participants assigned FICB and six of the 26 assigned usual care died within 6 months of hospital admission. Serious adverse events were also similar: 3/35 experimental versus 4/36 in usual care. Paramedics’ recognition of hip fracture had sensitivity of 49/64 (77%) with a positive predictive value of 46/57 (81%). We received quality of life questionnaires for 30 of 49 patients (61%) at 1 month and 12 of 17 (71%) at 6 months. Patient satisfaction was similar: experimental mean 3.4 (n = 20) versus 3.5 (n = 13) for usual care. Conclusions RAPID met all progression criteria within reasonable limits. As equipoise remains, we plan to undertake a fully powered multi-centre trial to test clinical and cost effectiveness of paramedic-administered FICB at the scene of hip fracture. Trial registration ISRCTN 60065373 sought 5 November 2015. Electronic supplementary material The online version of this article (10.1186/s40814-019-0454-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Greg Fegan
- 1Swansea University Medical School, Swansea, UK
| | - Simon Ford
- Swansea Bay University Health Board, Swansea, UK
| | - Katy Guy
- Swansea Bay University Health Board, Swansea, UK
| | - Sian Jones
- 3Patient and public representative, c/o Swansea University Medical School, Swansea, UK
| | - Leigh Keen
- 4Welsh Ambulance Services NHS Trust, Saint Asaph, UK
| | | | | | - Ian Pallister
- 1Swansea University Medical School, Swansea, UK.,Swansea Bay University Health Board, Swansea, UK
| | - Nigel Rees
- 4Welsh Ambulance Services NHS Trust, Saint Asaph, UK
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Evans BA, Brown A, Bulger J, Fegan G, Ford S, Guy K, Jones SI, Keen L, Khanom A, Longo M, Pallister I, Rees N, Russell IT, Seagrove AC, Watkins A, Snooks H. Paramedics' experiences of administering fascia iliaca compartment block to patients in South Wales with suspected hip fracture at the scene of injury: results of focus groups. BMJ Open 2019; 9:e026073. [PMID: 30772863 PMCID: PMC6398707 DOI: 10.1136/bmjopen-2018-026073] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To explore paramedics' experience of delivering fascia iliaca compartment block (FICB) to patients with suspected hip fracture at the scene of injury. DESIGN Focus groups within a randomised controlled trial. SETTING Paramedics based at ambulance stations in the catchment area of one Emergency Department in South Wales, recruited and trained in a feasibility study about an alternative to routine prehospital pain management for patients with suspected hip fracture. PARTICIPANTS 11 paramedics. INTERVENTION Paramedic-administered FICB to patients with suspected hip fracture. We randomly allocated eligible patients to FICB, a local anaesthetic injection directly into the hip region-or usual care, most commonly morphine - using audited scratch cards. OUTCOMES Paramedics' experiences of administering FICB gathered through thematic analysis of interview transcripts by two researchers, one paramedic and one lay member. RESULTS Respondents believed that FICB was a suitable intervention for paramedics to deliver. It aligned with routine practice and was within people's capabilities. They said it took up to 10 minutes longer than usual care to prepare and deliver, in part due to nervousness and unfamiliarity with a new procedure. They praised the training provided but said they were anxious about causing harm by injecting into the wrong location. Confidence increased after one paramedic team successfully treated a patient for local anaesthetic toxicity. Reported challenges related to the emergency context: patients often waited many hours for ambulance arrival; moving patients exacerbated their pain; family and neighbours were present as paramedics administered treatment. CONCLUSIONS Paramedics are willing and able to administer FICB to patients with suspected hip fracture before ambulance transport to hospital. Feasibility study findings will inform further research. TRIAL REGISTRATION NUMBER ISRCTN60065373; Pre results.
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Affiliation(s)
| | - Alan Brown
- Public contributor, c/o Swansea University, Swansea, UK
| | | | - Greg Fegan
- Medical School, Swansea University, Swansea, UK
| | - Simon Ford
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
| | - Katy Guy
- Abertawe Bro-Morgannwg University Health Board, Cardiff, UK
| | - SIan Jones
- Public contributor, c/o Swansea University, Swansea, UK
| | - Leigh Keen
- The Welsh Ambulance Services NHS Trust, Swansea, UK
| | | | | | - Ian Pallister
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
| | - Nigel Rees
- Pre-hospital Emergency Research Unit, Welsh Ambulance Services NHS Trust, Cardiff, UK
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Matthews R, McCaul M, Smith W. A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town. Afr J Emerg Med 2017; 7:24-29. [PMID: 30456102 PMCID: PMC6234150 DOI: 10.1016/j.afjem.2017.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 10/21/2016] [Accepted: 01/10/2017] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa. METHODS A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider. RESULTS A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66-74) cases, nitrates in 197 (37%, 95% CI 33-41) and ketamine in 9 (1.7%, 95% CI 1-3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70-79) cases, with the median dose being 4 mg (IQR 3-6). Single doses were administered to 268 (72.2%, 95% CI 67-77) morphine administrations, five (56%, 95% CI 21-86) ketamine administrations and 161 (82%, 95% CI 76-87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2-4). DISCUSSION Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.
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Affiliation(s)
- Ryan Matthews
- Cape Peninsula University of Technology, Department of Emergency Medical Care, PO Box 1906, Bellville 7535, South Africa
| | - Michael McCaul
- Stellenbosch University, Centre for Evidence-based Health Care (CEBHC), PO Box 241, Cape Town 800, South Africa
| | - Wayne Smith
- University of Cape Town, Division of Emergency Medicine and Provincial Government of the Western Cape, Private Bag x24, Bellville 7535, South Africa
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Bulger JK, Brown A, Evans BA, Fegan G, Ford S, Guy K, Jones S, Keen L, Khanom A, Pallister I, Rees N, Russell IT, Seagrove AC, Snooks HA. Rapid analgesia for prehospital hip disruption (RAPID): protocol for feasibility study of randomised controlled trial. Pilot Feasibility Stud 2017; 3:8. [PMID: 28163926 PMCID: PMC5282771 DOI: 10.1186/s40814-016-0115-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 12/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adequate pain relief at the point of injury and during transport to hospital is a major challenge in all acute traumas, especially for those with hip fractures, whose injuries are difficult to immobilise and whose long-term outcomes may be adversely affected by administration of opiate analgesics. Fascia iliaca compartment block (FICB) is a procedure routinely undertaken by doctors and nurses in the emergency department for patients with hip fracture but not yet evaluated for use by paramedics at the scene of emergency calls. In this feasibility study, we aim to test whether FICB administered by paramedics at the scene of participants' hip fractures is feasible, safe and acceptable. This will enable us to decide whether to proceed to a fully powered, multi-centre pragmatic randomised trial to evaluate whether the procedure is effective for patients and worthwhile for the NHS. METHODS/DESIGN In this study, we propose to recruit ten paramedics in an urban area of South Wales. We will train them to carry out FICB when they attend patients with hip fracture. We will randomly allocate eligible patients to FICB or usual care using audited scratch cards. We will follow up participants to assess measurability of key outcomes including quality of life, pain scores, adverse events, length of stay in hospital, acceptability to patients and compliance of paramedics. We will assess whether the findings meet specified feasibility criteria and, if so, plan a full trial. DISCUSSION This study will enable us to recommend whether to undertake a definitive trial of FICB by paramedics for hip fracture. TRIAL REGISTRATION ISRCTN60065373.
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Affiliation(s)
- Jenna K. Bulger
- Swansea University Medical School, ILS2, Singleton Campus, Swansea University, SA2 8PP Swansea, UK
| | | | - Bridie A. Evans
- Swansea University Medical School, ILS2, Singleton Campus, Swansea University, SA2 8PP Swansea, UK
| | - Greg Fegan
- Swansea University Medical School, ILS2, Singleton Campus, Swansea University, SA2 8PP Swansea, UK
| | - Simon Ford
- Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Katy Guy
- Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | | | - Leigh Keen
- Welsh Ambulance Services NHS Trust, Swansea, UK
| | - Ashrafunnesa Khanom
- Swansea University Medical School, ILS2, Singleton Campus, Swansea University, SA2 8PP Swansea, UK
| | - Ian Pallister
- Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, Swansea, UK
| | - Ian T. Russell
- Swansea University Medical School, ILS2, Singleton Campus, Swansea University, SA2 8PP Swansea, UK
| | - Anne C. Seagrove
- Swansea University Medical School, ILS2, Singleton Campus, Swansea University, SA2 8PP Swansea, UK
| | - Helen A. Snooks
- Swansea University Medical School, ILS2, Singleton Campus, Swansea University, SA2 8PP Swansea, UK
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Abstract
This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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